O'Keeffe and beyond in New Britain

“Jimson Weed/White Flower No. 1 ‘‘ (oil on canvas, 1932) by Georgia O’Keeffe, in the show “The Beyond: Georgia O'Keeffe and Contemporary Art’’ at the New Britain (Conn.) Museum of American Art. This innovative exhibition features more than three dozen of O'Keeffe's most important works alongside 20 contemporary artists that evoke and elaborate upon the iconography of O'Keeffe's career. New Britain is an old factory town in the middle of the Nutmeg State with a surprisingly important museum that was started in the city’s salad days.

At PCFR: Explaining the refugees at our border; Brazil turns right; Indian castes there and here; Tough little Taiwan

Next at the PCFR: Central American challenge; Brazil’s new boss; Indian caste system there and here and PRI foreign correspondence; Plucky Taiwan

Herewith some upcoming talks at the Providence Committee on Foreign Relations (thepcfr.org; pcfremail@gmail.com), which are held at the Hope Club. Please consult thepcfr.org for information on how to join the organization and other information about the PCFR.

We much enjoyed the March 14 talk by Miguel Head, who spent the past decade as a senior adviser to the British Royal Family!

At the  next meeting, on  Thursday, April 4, James Nealon, the former U.S. ambassador to Honduras, will talk about Central America in general and Honduras in particular, with a focus on the conditions leading so many people there to try to flee to the United States – and what the U.S. can and should do about it.

A career Foreign Service officer,  Nealon held posts in Canada, Uruguay, Hungary, Spain, and Chile before assuming his post as Ambassador to Honduras in August 2014; Nealon also served as the deputy of Gen. John F. Kelly, while Kelly was in charge of the United States Southern Command.

After leaving his ambassadorship in 2017, Nealon was named assistant secretary for international engagement at the Department of Homeland Security by Kelly in July. During his time as assistant secretary, Nealon supported a policy of deploying Homeland Security agents abroad. He resigned his post on Feb. 8, 2018, due to his disagreements with the immigration policy of Donald Trump, and, specifically, the withdrawal of temporary protected status for Hondurans.

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Then, on Wednesday, April 10, the speaker will be Prof. James Green, who will talk about the political and economic forces that have led to the election of  Brazil’s new right-wing president,  Jair Bolsonaro – and hazard some guesses on what might happen next. Professor Green is one of the world’s leading experts on that huge country. (The PCFR strives to avoid having dinners two weeks in a row but in some rare cases the availability of expert speakers on urgent current topics forces this crowding.)

Professor Green, who teaches at Brown, is the Carlos Manuel de Céspedes Professor of Latin American History and director of Brown’s Brazil Initiative, Distinguished Visiting Professor (Professor Amit) at Hebrew University, in Jerusalem, and the Executive Director of the Brazilian Studies Association (BRASA), which is now housed at the Watson Institute at Brown.

Green served as the director of the Center for Latin American and Caribbean Studies at Brown from 2005 to 2008. He was president of the Brazilian Studies Association (BRASA) from 2002 until 2004, and president of the New England Council on Latin American Studies (NECLAS) in 2008 and 2009. 

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Then on May 16 comes Phillip Martin,  senior investigative reporter for WGBH News and a contributing reporter to Public Radio International’s The World, a co-production of WGBH, the BBC and PRI -- a program that he helped develop as a senior producer in 1995.  Basing his comments on his recent reporting for PRI, he’ll talk about the Indian caste system and how it extends into the Indian immigrant community in the U.S. He’ll also talk about the  very challenging role of foreign correspondents in contemporary journalism. Many PCFR members have probably often heard his resonant voice on public radio.

Phillip is the recipient of the Society of Professional Journalists 2017 Sigma Delta Chi award for Best Investigative Reporting and the 2014 national Edward R. Murrow Award for Best Investigative Reporting(large-market radio ). He also was honored with 2013 New York Festivals and United Nations UNDPI Gold Awards. He was part of a team of reporters that was honored in 2002 with a George Foster Peabody Award to NPR for coverage of the September 11th terrorist attacks in the U.S. He has received numerous other journalism and civic engagement honors over the course of his career. 

He earned a master's degree in law and diplomacy from the Fletcher School of Law and Diplomacy at Tufts University and studied international protection of human rights law at Harvard Law School. 

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On Tuesday, June 4, Douglas Hsu, a senior Taiwanese diplomat who currently oversees that nation’s interests in New England, will speak to us about current political and economic conditions in that nation (one of Rhode Island’s largest export markets), and China’s military and other threats to Taiwan.

Those old 'railroad hotels'

Above, the Nathan Hale Hotel in Willimantic, Conn., in better days. Below, the Hooker Hotel in recent dark days.

TFrom Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com

The New England News Collaborative (NENC), a consortium of NPR stations, has a nice piece on its Web site about efforts to fix up that old textile mill town of Willimantic, Conn. (which called itself “The Thread City’’).

Much of the story focused on whether to tear down two old abandoned and adjacent Main Street hotels. One is the Nathan Hale Hotel, built in the Twenties and named after the Connecticut man who became a soldier and spy in the Revolutionary War and was executed by the British for his brave work. (He’s the official “State Hero’’ of Connecticut.) The other is the unfortunately named Hooker Hotel built in 1887 (where in some of its later years some women of that age-old profession were known to ply their wares). In fact, the building is named for the respectable Seth Chauncey Hooker, its developer.

Both the hotels were what used to be called “railroad hotels’’. They were close to the train stations in their towns or cities and were heavily used by salesmen, such as Willy Loman, the sad protagonist of the play Death of a Salesman.

Most of these hotels have long since disappeared with the demise of rail passenger service to many towns and even cities and its replacement, by car travel, aided and abetted by the Interstate Highway System. The rise of car culture led to most hotels and motels being built away from downtowns, on suburban shopping strips and/or close to the nearest Interstate – with lots of parking.

Marriotts and other chains, etc., can be very nice but I miss the quirky atmosphere of these old downtown hotels in New England, where local luminaries and others would gather, often almost every day, to eat in their dining rooms (Yankee pot roast! Finnan haddie!) and attend meetings of local civic organizations. Their lobbies were almost like town halls.

To read and hear the NENC’s piece, please hit this link:

https://nenc.news/historic-willimantic-connecticut-to-demolish-rough-reputation

A beach day for masochists

Moody Beach, in Wells, Maine, in the off-season.

It was cold and windy, scarcely the day
to take a walk on that long beach
Everything was withdrawn as far as possible,
indrawn: the tide far out, the ocean shrunken,
seabirds in ones or twos.
The rackety, icy, offshore wind
numbed our faces on one side;
disrupted the formation
of a lone flight of Canada geese;
and blew back the low, inaudible rollers
in upright, steely mist.

From “The End of March,’’ by Elizabeth Bishop (1911-1979), who was born in Worcester and died in Boston but traveled widely in between. For many years she had a summer place on the Maine Coast.

Jessicah Pierre: Those elite college 'legacy' admissions

Dartmouth Hall at Dartmouth College, in Hanover, N.H.

Via OtherWords.org

In what’s being called the largest college admissions scam ever, a number of wealthy parents, celebrities, and college prep coaches have been accused of offering large bribes to get rich students into Ivy League and other elite schools, regardless of their credentials. The Ivy League includes Brown, Cornell, Columbia, Dartmouth, Harvard, the University of Pennsylvania, Princeton and Yale.

The parents facing charges allegedly paid up to $6.5 million to get their kids into college.

Shocking as it is, this is hardly a new phenomenon in higher education. Wealthy and privileged students have always had an upper hand in being accepted to prestigious universities.

They’re called “legacy preferences.”

“Many U.S. colleges admit ‘legacies,’ or students with a family connection to the university, at dramatically higher rates than other applicants,” The Guardian explains, because “they are widely seen as a reliable source of alumni donations.”

Some of our countries most prominent figures have benefited from legacy preferences. When applying to Harvard, future president John F. Kennedy noted that his father was an alumnus. And although his academic record was unspectacular, he was admitted into the Ivy League school.

The same can be said for George W. Bush, whose father and grandfather graduated from Yale. Despite his “lackluster grades,” The Guardian reported, Bush was accepted.

This overt — and legal — preference for the wealthy and powerful goes back at least a century. Yet when the children of middle class families are denied admission, some families have laid the blame on affirmative action programs for students of color, who’ve historically faced discrimination.

As the college admissions process becomes more competitive, campaigns against affirmative action have revved up immensely. In 2016, Abigail Fisher challenged the University of Texas at Austin’s race-conscious admissions program after being rejected when she applied for a university program designed for the top 10 percent of her class.

Despite not having the credentials to get into the program, Fisher cited affirmative action as the reason why she was denied. In other words, she claimed she was being discriminated against because she was white. Her case made it all the way to the Supreme Court, which ruled that affirmative action is in fact constitutional and doesn’t hurt white students.

In fact, even with programs like affirmative action, according to the National Center for Educational Statistics, racial divides at universities still remain. While college enrollment is increasing across the board, it found that enrollment rates for college-aged white students (42 percent) remain higher than for both black students (36 percent) and Hispanic students (39 percent.)

Meanwhile, a 2018 analysis of Harvard’s admissions process found that legacy applicants were accepted at a rate of nearly 34 percent from 2009 to 2015. That’s more than five times higher than the rate for non-legacies over the same six-year period: just 5.9 percent.

It’s clear that students like Abigail Fisher are picking the wrong fight when it comes to discrimination in the college admissions process.

The high-level of corruption of legacy admissions hurts the majority of students, regardless of race. So too do the parents spending millions on bribes. But that’s how inequality thrives.

Today’s college admissions scandal is just another illustration of the rich encouraging working- and middle-class people to turn against each other — and blame people of color — while they quietly rig the game for themselves.

Instead of pointing the finger at each other, the victims of these manipulations should come together to take the monster of economic privilege down.

Jessicah Pierre is the inequality media specialist at the Institute for Policy Studies.

Stephanie McGrath: Watching emerging trends in N.E. higher ed and workforce development

The New Hampshire State House, in Concord.

From The New England Journal of Higher Education, a service of The New England Board of Higher Education (nebhe.org)

BOSTON

Across New England, the days are getting get much longer, everyone is hoping real spring weather is just around the corner, and each state’s legislative session is firmly underway.

While it’s still relatively early in the current sessions, at NEBHE we’re taking a first look at the major issues and trends we see emerging in the region’s legislatures related to higher education and workforce development. Some topics are expected: affordability, student loan debt, and college closures / mergers /  acquisitions / collaborations. Other bills touch on emerging issues: incentives for employers who provide and/or pay for employee training, and decreasing the cost of course materials and textbooks through the use of open educational resources.

                 2019 Legislative Session Schedule
State                                                     Convened       Adjourns
Connecticut General Assembly…………… Jan. 9……….. June 5
Maine State Legislature………………… Dec. 5 (’18)…… June 19
Massachusetts General Court…………….. Jan. 2……….. Dec. 31
New Hampshire General Court………….. Jan. 2 ……. Late June
Rhode Island General Assembly…………. Jan. 1……… Mid-July
Vermont General Assembly……………….. Jan. 9……… Mid-May

Let’s take a deeper dive into what we see as the most significant issues to watch in 2019…

Affordability and Student Loan Debt

Every New England state has introduced legislation related to issues around college affordability and student loan debt.

Following what has quickly become a national trend, a number of new bills propose making higher education in New England free, tuition-free, or debt-free for various constituencies. Most notably, Rhode Island Gov. Gina Raimondo has proposed expanding the state’s Promise scholarship program to Rhode Island College to make the last two years of its four-year degree tuition-free. The proposal will need the legislature’s approval, but it faces stiff competition for funds from a suggested program for universal pre-kindergarten education, also put forth by Gov. Raimondo. This year Vermont also introduced a bill (S.38) that would create the Vermont Promise Scholarship Program to provide tuition-free scholarships to in-state students who attend a Vermont State College.

New Hampshire is seeking to tackle the issue of college affordability by incentivizing greater civic engagement. The General Court has submitted a bill (268-FN) that would provide in-state undergraduate tuition rates at any institution in the University System of New Hampshire (USNH) for any individual who can demonstrate that they are registered to vote in the state. The greatest roadblock this bill faces is that, if enacted, USNH would need to compensate for the resulting revenue shortfall. To do so, the bill proposes increasing tuition rates and/or decreasing institutional aid to the USNH’s 25,000 students — which may come close to nullifying any of the intended benefits with regard to offering in-state tuition.

Two states, Maine (S.P.285) and Massachusetts (HD.1069) have submitted proposals to establish a “Student Loan Bill of Rights” to provide borrowers with a minimum level of consumer protection and, in Maine’s case, to incentive college graduates to remain in-state post-graduation. The proposed Bill of Rights in Massachusetts had passed the state Senate unanimously in the 2018 session but is being reintroduced because it did not receive action in the House of Representatives. If passed in either state, Maine and/or Massachusetts would follow Connecticut, which enacted a Student Loan Bill of Rights in 2015. Similarly Rhode Island (S-0018) has submitted a resolution to request the creation of a working group to review make recommendation regarding how the state can better protect education loan borrowers.

Closures, Mergers, Acquisitions and Collaborations

Given the demographic headwinds New England’s postsecondary institutions are facing, it should come as no surprise that many state legislatures have introduced bills to tackle the growing problem of school closures, mergers and acquisitions. In Massachusetts, Gov. Charlie Baker issued an emergency Senate bill (SD.2183) that, if passed, would require the Bay State’s degree-granting higher education institutions notify the Board of Higher Education of any financial liabilities or risks it faces, as well as a contingency closure plan. Connecticut has also proposed legislation (H.B.6474, S.B.749) that would prohibit the closure or merger of any of its public institutions of higher education without prior review and consent of the state’s General Assembly, while Connecticut State Colleges and Universities President Mark Ojakian continues to attempt to successfully consolidate all 12 community colleges into a single statewide college by 2023. Other states, such as Vermont, are beginning to consider ways to head off corollary issues at the pass by looking into potential solutions and best practices for handling student records after an institution’s closure, though no formal legislation has yet been filed.

Newly Emerging Issues

Beyond the two biggest topic areas above, other common issues are cropping up in states’ proposed legislation. Some of these include:

Employer tax credits for education loan assistance

Both Connecticut (S.B.435) and Massachusetts (S.1689) have introduced bills that would provide tax credits to employers that assist employees with their education loan payments.

Facilitation of affordable educational resources

Three states have pending legislation that falls under this umbrella: Connecticut, Maine, and Massachusetts. The bill in Maine (H.P.452) would award grants of at least $1,000 to low-income students to aid in the purchase of course textbooks. Connecticut (H.B.7162) and Massachusetts (H.1249) seek to mitigate the cost of course materials at higher education institutions by establishing special commissions to explore ways to improve the utilization of open educational resources (OERs) and other digital learning technologies.

You can view a round-up of all this session’s legislation pertaining to higher education and workforce development in the region here. NEBHE will continue to track these bills and provide regular updates on their progress, so stay tuned!

Stephanie (Murphy) McGrath is a NEBHE staffer.

'Spring faintly cries'

With rushing winds and gloomy skies

The dark and stubborn Winter dies:

Far-off, unseen, Spring faintly cries,

Bidding her earliest child arise; March!

— Bayard Taylor

Fred Schulte: Death by 1,000 clicks: When electronic health records went wrong

From Kaiser Health News

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.

5 KEY TAKEAWAYS

Patient harm: Electronic health records have created a host of risks to patient safety. Alarming reports of deaths, serious injuries and near misses — thousands of them — tied to software glitches, user errors or other system flaws have piled up for years in government and private repositories. Yet no central database exists to compile and study these incidents to improve safety.

Signs of fraud: Federal officials say the software can be misused to overcharge, a practice known as “upcoding.” Some doctors and health systems are alleged to have overstated their use of the new technology, a potentially enormous fraud against Medicare and Medicaid likely to take years to unravel. Two software makers have paid a total of more than $200 million to settle fraud allegations.

Gaps in interoperability: Proponents of electronic health records expected a seamless system so patients could share computerized medical histories in a flash with doctors and hospitals anywhere in the country. That has yet to materialize, largely because officials allowed hundreds of competing firms to sell medical records software unable to exchange information.

Doctor burnout: Many doctors say they spend half their day or more clicking pulldown menus and typing rather than interacting with patients. An emergency room doctor can be saddled with making up to 4,000 mouse clicks per shift. This has fueled concerns about doctor burnout, which in January the Harvard T.H. Chan School of Public Health and Massachusetts Medical Society called a “public health crisis.”

Web of secrets: Entrenched policies continue to keep software failures out of public view. Vendors of electronic health records have imposed contractual “gag clauses” that discourage buyers from speaking out about safety issues and disastrous software installations — and some hospitals fight to withhold records from injured patients or their families.

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 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.

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.”

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.)

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.

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.

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 Web site 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.

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.

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.

Fred Schulte is a Kaiser Health News journalist.

Fred Schulte: fschulte@kff.org, @fredschulte

John Sarbanes/Michael Brune: To save the environment, clean up Washington

Average global temperatures from 2014 to 2018 compared to a baseline average from 1951 to 1980, according to NASA's Goddard Institute for Space Studies.

From OtherWords.org

For decades, majorities of Americans have favored swift, meaningful action on climate change. They understand that we must transition away from dirty fuels and toward clean, renewable energy. Yet despite this overwhelming support, Congress has repeatedly failed to act.

This jarring disconnect between what the public wants to see and what Washington is prepared to deliver doesn’t just threaten the health and safety of everyone in our country — it undermines the very principle of representative democracy.

The reason that Congress hasn’t acted is an open secret.

Follow the trail of the millions of dollars in campaign contributions from corporate polluters over the years, and you’ll find countless lawmakers who’ve worked to block action on climate change. The special interests that are hostile to our environment have designed a sophisticated toolkit for furthering their narrow agenda, while avoiding accountability.

This assault on our democracy must end.

That’s why the new House majority passed H.R. 1, the For the People Act — a bold suite of reforms that will transform our government and our political system for the better.

Every provision of the bill is guided by one overarching imperative: restore the power and the voice of Americans who for too long have felt locked out of their own democracy.

First, H.R. 1 will push back hard against the influence of big money in our politics. That means bringing more transparency to the world of campaign finance so that polluters can no longer use shadowy organizations to hide their political spending.

In addition, by building a new system of citizen-owned elections that amplifies the power of small donors, H.R. 1 will reduce the financial influence of PACs and big corporations. The result will be environmental policy made for the public interest, not the interests of the fossil fuel industry.

Second, H.R. 1 will make sure that public officials serve the public, not themselves or some hidden group of industry patrons.

The bill extends conflict of interest rules to presidents and vice presidents and requires the release of their tax returns. It will prohibit members of Congress from serving on corporate boards and establish a code of ethics for the justices of the Supreme Court. And it will end the practice of corporations giving giant bonuses to employees who join the regulatory agencies overseeing them.

With strong disclosure rules and accountability provisions, it will prevent ethical corruption of the kind that defined Scott Pruitt and undermined the mission of the EPA

Third, H.R. 1 will protect every citizen’s right to vote and tear down barriers to the ballot box. That will help Americans send lawmakers to Washington who will act on climate, protect our environment, and make our air safe to breathe and our water safe to drink.

That means promoting national automatic voter registration, expanding early and absentee voting, ending voter roll purging, and providing relief from discriminatory voter ID laws.

H.R. 1 also ensures the integrity of our elections by committing Congress to build a record of voter suppression that demonstrates the need to restore the Voting Rights Act, ending partisan gerrymandering, and safeguarding our election infrastructure from interference.

With H.R. 1, we have a once-in-a-generation opportunity to clean up Washington, make our democratic process more fair and inclusive, and insist that Congress respond to the will of the many, not the money. Doing so will remove long standing barriers that have slowed and blunted climate action.

Michael Brune is executive director of the Sierra Club. Rep. John Sarbanes (D-MD)
authored H.R. 1.

Those delusional dreams

David Warsh: Long-term economic stagnation may be in the cards

This chart compares U.S. potential GDP under two Congressional Budget Office forecasts (one from 2007 and one from 2016) versus the actual GDP. It is based on a similar diagram from economist Lawrence Summers from 2014.[24]

SOMERVILLE, Mass.

Sluggish economic growth has generated a number of catch phrases to describe the collective experience – “lost” decades, secular stagnation, the Japanese disease.  There can be little doubt that the U.S. has been living through such a period.  The expansion since June 2009, the trough of the last recession, is nearing the record set in the 1990s, 120 months, but no one will mistake the last 10 years for the wild and wooly ‘90s.

True, the unemployment rate is today very low. But GNP growth itself has been sub-par, wages have risen only slowly, interest rates have remained low, inflation has stayed below target, and the federal deficit has grown instead of vanishing. That’s what Lawrence Summers had in mind in 2013 when he revived the long-ago prophecy of his Harvard predecessor Alvin Hansen to warn of secular stagnation.

How long?  Indefinitely, answered Summers, without a considerable overhaul of the economic dogma that informs politics and policy.

Summers reiterated all this earlier this month in a paper with Lukasz Rachel, of the London School of Economics, a leader of the rising generation of macroeconomists, at the spring meeting of the Brookings Panel on Economic Activity. A savings glut developed over the course of the last generation was driving down the so-called neutral rate of interest – the point at which savings and investment balance at full employment. Bubbles and other sorts of asset misallocation remain a threat as long as interest rates remain low and out of alignment.

Bigger government deficits than those now considered prudent will be required, the economists say, to soak up private savings on the one hand, and, on the other, devise novel long-term investments designed make private investment attractive again.

This time Summers added a further warning.  Given that central banks have slashed their lending rates by 5 percentage points or more to combat recessions in the past, “there is the question of whether enough room can be generated to stabilize the economy when the next recession hits.”  Monetary policy may have reached its limits.

Rachel and Summers’s analysis is technical economics.  You can read it here. Financial Times columnist Martin Wolf’s account of their paper is here. Summers added some details in an op-ed article in The Washington Post that makes the argument less of an abstraction.

Hansen, an early convert to Keynesian views and for some years thereafter its leading American apostle, had feared that demographic trends and diminishing technological opportunities were reaching  a point  at which only government deficit spending could keep the economy at full employment.

[It was in his presidential address to the American Economic Association, in 1938, that Hansen spelled out his view. Slowing population growth, the closing of the American frontier, and the end of the 19th Century capital-goods boom would mean “sick recoveries which die in their infancy and which feed on themselves and leave a hard and unmovable core of unemployment.”]

That didn’t happen, writes Summers. “Sufficient remedies were found initially in wartime military spending, then in massive national projects such as building out the suburbs and reducing saving by allowing Social Security to meet retirement needs and making consumer credit widely available.”  But with the extravagant growth of private savings around the world since the 1980s, perhaps the situation that Hansen feared has risen anew.  Summers writes in the op-ed:

What has happened to private saving and private investment? Many things, including increases in saving caused by people having fewer children, more inequality, longer retirement periods and increased uncertainty. Probably more important, demand for private investment has fallen off as the economy’s structure has changed. Computing power costs a tiny fraction of what it used to. Malls have been replaced by e-commerce. People prefer small urban apartments to large suburban houses. Cars and appliances need to be replaced less often. In any event, the end of labor force growth means less demand for new capital.

In their paper, much the news Rachel and Summers offer is empirical. Real interest rates would have declined far more over the last fifty years, the economists say, if it weren’t for the large increases in government debt, pay-as-you-go pensions, and public health insurance expenditures that were put in place by, among other things, “the Reagan revolution.”  That neutral rate of interest, a conceptual apparatus designed to guide central bank policy, may have declined as much as 7 percentage points since 1970s, as savings have grown and tempting private investment opportunities have shrunk. The neutral rate would be several percentage points negative without the run-up to the level today’s trillion-dollar annual deficit. Summers continued.

The traditional Keynesian view, in which permanent depression is possible, is more right than the New Keynesian approach in which employment is attributed only to temporary price rigidities.

What to do, then, about all those private savings seeking “yield,” or at least a seemingly fair return? Summers offers a short list of options: bigger budget deficits, improved Social Security designed to reduce retirement savings, redistributions of income to poorer consumers with higher spending propensities, reductions in monopoly power, investment mandates (such as the retirement of coal-fired power plants) and other investment incentives.

Are there any changes in the offing of comparable magnitude to those that after World War II made Alvin Hansen seem an alarmist? Perhaps.  The world seems to be selling again into a long-lasting global contest, this time between the United States and China.  The problem posed by global warming is very real; what remains to be seen is the alacrity with which it is taken up.

And it’s worth remembering that all this takes place against the backdrop of the narrative that Thomas Piketty set out in 2014. In Capital in the Twenty-First Century (Harvard), the French economist reintroduced an argument even older than secular stagnation – the proposition that the rich were getting richer much faster that the world economy was growing, and that this inequality was profoundly destabilizing

A decade after the financial crisis cast macroeconomics into low regard, it is back in style.

David Warsh, a veteran political and economist essayist, and an economic historian, is proprietor of Somerville-based economicprincipals. com, where this piece first ran.

Spring PCFR meetings: Central American refugees; Brazilian boss; Indian caste system there and here; Tiny, tough Taiwan

President Trump inspects prototypes for his border wall last year in San Diego.

Next at the PCFR: Central American challenge; Brazil’s new boss; Indian caste system there and here and PRI foreign correspondence; Plucky Taiwan

Herewith some upcoming talks at the Providence Committee on Foreign Relations (thepcfr.org; pcfremail@gmail.com), which are held at the Hope Club. Please consult thepcfr.org for information on how to join the organization and other information about the PCFR.

We much enjoyed the March 14 talk by Miguel Head, who spent the past decade as a senior adviser to the British Royal Family!

At the  next meeting, on  Thursday, April 4, James Nealon, the former U.S. ambassador to Honduras, will talk about Central America in general and Honduras in particular, with a focus on the conditions leading so many people there to try to flee to the United States – and what the U.S. can and should do about it.

A career Foreign Service officer,  Nealon held posts in Canada, Uruguay, Hungary, Spain, and Chile before assuming his post as Ambassador to Honduras in August 2014; Nealon also served as the deputy of Gen. John F. Kelly, while Kelly was in charge of the United States Southern Command.

After leaving his ambassadorship in 2017, Nealon was named assistant secretary for international engagement at the Department of Homeland Security by Kelly in July. During his time as assistant secretary, Nealon supported a policy of deploying Homeland Security agents abroad. He resigned his post on Feb. 8, 2018, due to his disagreements with the immigration policy of Donald Trump, and, specifically, the withdrawal of temporary protected status for Hondurans.

xxx

Then, on Wednesday, April 10, the speaker will be Prof. James Green, who will talk about the political and economic forces that have led to the election of  Brazil’s new right-wing president,  Jair Bolsonaro – and hazard some guesses on what might happen next. Professor Green is one of the world’s leading experts on that huge country. (The PCFR strives to avoid having dinners two weeks in a row but in some rare cases the availability of expert speakers on urgent current topics forces this crowding.)

Professor Green, who teaches at Brown, is the Carlos Manuel de Céspedes Professor of Latin American History and director of Brown’s Brazil Initiative, Distinguished Visiting Professor (Professor Amit) at Hebrew University, in Jerusalem, and the Executive Director of the Brazilian Studies Association (BRASA), which is now housed at the Watson Institute at Brown.

Green served as the director of the Center for Latin American and Caribbean Studies at Brown from 2005 to 2008. He was president of the Brazilian Studies Association (BRASA) from 2002 until 2004, and president of the New England Council on Latin American Studies (NECLAS) in 2008 and 2009. 

            xxx

Then on May 16 comes Phillip Martin,  senior investigative reporter for WGBH News and a contributing reporter to Public Radio International’s The World, a co-production of WGBH, the BBC and PRI -- a program that he helped develop as a senior producer in 1995.  Basing his comments on his recent reporting for PRI, he’ll talk about the Indian caste system and how it extends into the Indian immigrant community in the U.S. He’ll also talk about the  very challenging role of foreign correspondents in contemporary journalism. Many PCFR members have probably often heard his resonant voice on public radio.

Phillip is the recipient of the Society of Professional Journalists 2017 Sigma Delta Chi award for Best Investigative Reporting and the 2014 national Edward R. Murrow Award for Best Investigative Reporting(large-market radio ). He also was honored with 2013 New York Festivals and United Nations UNDPI Gold Awards. He was part of a team of reporters that was honored in 2002 with a George Foster Peabody Award to NPR for coverage of the September 11th terrorist attacks in the U.S. He has received numerous other journalism and civic engagement honors over the course of his career.

He earned a master's degree in law and diplomacy from the Fletcher School of Law and Diplomacy at Tufts University and studied international protection of human rights law at Harvard Law School. 

xxx

On Tuesday, June 4, Douglas Hsu, a senior Taiwanese diplomat who currently oversees that nation’s interests in New England, will speak to us about current political and economic conditions in that nation (one of Rhode Island’s largest export markets), and China’s military and other threats to Taiwan.

Small colleges' existential crisis

From Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com

The number of small nonelite New England private colleges that are closing because of dwindling finances and enrollments continue to grow. The latest is Green Mountain College, in tiny Poultney, Vt., and the College of St. Joseph, in the small Vermont city of Rutland.

This is sad because some of these colleges have very usefully served to help educate those whose academic backgrounds and family issues may have blocked them from getting into richer and/or more prestigious institutions. But these closings can also be a heavy economic blow to the small towns and cities so many are situated.

Can online courses take the place of most of these little colleges? How important is in-person teaching? To me, very.

Eating from the same tree

Two taps in a maple tree, using plastic tubing for collecting sap to be boiled to make maple syrup.

“We’re taping trees my grandparents’ parents” tapped. We look at it like this: a corn farmer can eat corn from the same field his great-grandfather planted, but he can’t eat from the same stalk. But an old syrupin’ family eats from the same tree.’’

-- New England farmer Tom Hunter quoted in Blue Highways, by William Least Heat Moon

Jordan Rau: Trump cuts way back on fines for nursing homes

From Kaiser Health News

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 switchedfrom 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.)

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.”

Jordan Rau: jrau@kff.org, @JordanRau

Destination bridge

What the new bridge will look like.

From Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com

The new pedestrian bridge to go over the Providence River, with its opening scheduled for later this year, is indeed expensive. GoLocal reports, for example, that the project is now estimated to cost $1,470 a square foot – 145 percent more, for example, than the estimated per-square-foot cost to replace the Henderson Bridge (aka “Red Bridge’’), linking Providence’s East Side and East Providence!

But the pedestrian bridge, in downtown Providence (“The Creative Capital’’?), will have aesthetic features (including custom-fabricated steel and a wooden (love it!) decking system) befitting its location (essentially on the campus of the Rhode Island School of Design, perhaps America’s most famous art school). It will not only be a pleasant way to travel between downtown and the East Side/College Hill/Fox Point; it will also be a destination point, where many people will linger on nice days. Sort of a mini-park. It should even lure some tourists (and their restaurant, etc., dollars) to the city. So special attention and added costs seem reasonable.

To read the GoLocal piece, please hit this link.

Reflect on this

‘‘Meditation #9’’ (oil on canvas), by Betsyann Duval, in her show “Time Out: Meditations and Relections,’’ at Bromfield Gallery, Boston, through March 31. Her photographs and paintings examine reflections in water as a place of refuge.

Todd McLeish: Threats remain to National Monument off the Northeast coast

From ecoRI News (ecori.org)

The Northeast Canyons and Seamounts Marine National Monument, the only national monument in the Atlantic Ocean, remains controversial more than two years after it was designated by President Obama in September 2016.

Fishermen brought suit to overturn the designation — the suit was dismissed last October, but it’s being appealed — President Trump has threatened to use his executive authority to revoke the designation, despite uncertainties as to whether he can legally do so, and the Interior Department has recommended that the Trump administration reopen the monument to commercial fishing.

Peter Auster, however, argued in a lecture at Providence’s Roger Williams Park Zoo on Feb. 28 that the 4,900-square-mile area about 150 miles off Cape Cod is deserving of protection because of its high species diversity, wide variety of habitats, and its numerous creatures that are sensitive to disturbance.

A senior research scientist at Connecticut’s Mystic Aquarium, Auster was a key player in building the scientific case for why the area should be designated a national monument. He has led multiple research projects to explore the area using submersible vessels, remotely operated vehicles, and autonomous vehicles, all of which have revealed an unusual array of marine life, from “Dr. Seussian species” of fish to dozens of kinds of deep-sea corals.

“A dive into the canyons and seamounts demonstrates the magic of the ocean,” he said. “There’s a whole garden of organisms that live there.”

About the size of Connecticut, the monument includes two distinct areas, one that covers three canyons and one that covers four seamounts. (NOAA)

The monument includes a portion of the edge of the continental shelf, where the seafloor drops sharply from a depth of about 600 feet down to 3,000, and where four extinct underwater volcanoes jut upward from the seafloor. The monument got its name from those underwater volcanoes — called seamounts — and a number of canyons carved into the shelf edge by ancient rivers.

“Those canyons and seamounts create varied ecotones in the deep ocean with wide depth ranges, a range of sediment types, steep gradients, complex topography, and currents that produce upwelling, which creates unique feeding opportunities for animals feeding in the water column,” Auster said.

Using colorful photographs of rarely seen creatures to illustrate his presentation, Auster called the area a “biodiversity hot spot,” noting that at least 73 species of deep-sea corals live in the area, including 24 that were found there for the first time during a research expedition in 2013. Many of those corals serve as hosts to other creatures — crabs, shrimp, and starfish, for instance — that are only found on those particular corals.

New England Aquarium researchers have found that the monument’s surface waters serve as feeding grounds for an abundance of whales, sea turtles, sharks, and seabirds, as well as fish that migrate from the deep water to the surface every day to feed.

In addition, Maine Audubon recently discovered that the monument area is where many of the region’s Atlantic puffins spend the winter. And researchers from the Northeast Fisheries Science Center, in Woods Hole, Mass., found that significant numbers of the extremely rare True’s beaked whale, one of the deepest diving marine mammals in the world, spends the summer in monument waters.

Despite these recent discoveries, scientists say there is still a great deal to be learned about the area.

“We don’t yet know everything we need to know to manage the monument,” Auster said.

At least 73 species of deep-sea corals live in the area, including bamboo coral. (NOAA)

On his scientific to-do list is an assessment of the biological diversity of the area and how it’s distributed in the monument; an assessment of ecological change over time; a better understanding of species interactions; and an assessment of how the region has recovered from natural and human-caused disturbances.

While the status of the monument remains in limbo, a number of additional threats may be lurking. So far, commercial fishing has only impacted the shallow areas of the monument on the continental shelf, but Auster said there are increasing efforts to fish in the deeper waters. In addition, the Trump administration is advocating for expanded oil and gas exploration in the waters off the East Coast, and the growing seabed mining industry may see the seamounts as potentially valuable sites for methane hydrate mining or manganese crust mining.

While Auster seems somewhat confident that the monument designation will hold, and he’s already working on making the case for a second marine national monument in the Atlantic — this one at Cashes Ledge in the middle of the Gulf of Maine — he acknowledged that there are influential political forces at work that could derail the monument designation.

“Like every monument, there are people who suggest that it isn’t a good thing to conserve examples of our natural heritage for future generations,” Auster said. “The end of this story remains to be written.”

Rhode Island resident and author Todd McLeish runs a wildlife blog.

'Immensely disappointing' at USC

The unfortunately nicknamed “Tommy Trojan’’ statue on the campus of the University of Southern California.

On the college-admissions scandal, a letter from the president of the University of Southern California, in Los Angeles.

March 12, 2019

Dear USC Community, 

I want to inform you of an ongoing wide-ranging criminal investigation involving universities nationwide, including USC.  The government has made a public announcement and disseminated the charging documents.  The federal government has alleged that USC is a victim in a scheme perpetrated against the university by a long-time Athletics Department employee, one current coach and three former coaching staff, who were allegedly involved in a college admissions scheme and have been charged by the government on multiple charges. 

At this time, we have no reason to believe that Admissions employees or senior administrators were aware of the scheme or took part in any wrongdoing—and we believe the government concurs in that assessment.  The government has repeatedly informed us that it views USC as a victim and that these employees purposefully deceived USC.  

We have planned significant remedial efforts.  We will take all appropriate employment actions.  We will review admissions decisions.  We are identifying all funds received that may be connected to the government’s allegations.  And we will be implementing significant process and training enhancements to prevent anything like this from ever happening again. 

It is immensely disappointing that individuals would abuse their position at the university in this way.   

As our work on culture and values continues, we must take the appropriate action when we become aware of behavior that is contrary to our values.  I appreciate the efforts of the staff who diligently responded to the government’s investigation, and for the broad commitment of our community to address problems as we learn of them. 

We will continue to cooperate fully with all law enforcement and regulatory investigations.  

Any media calls can be referred to the USC Media Line 213-740-2215.

Dr. Wanda M. Austin

President

The Rise of China