Healthcare IT leaders urge industry to tackle fraud issue

By Bernie Monegain
12:00 AM

Healthcare fraud doesn't even get a mention in the recently released government plan for creating a nationwide health information network.

Donald W. Simborg, MD, headed a team that worked on the problem of fraud for the Office of the National Coordinator. It's a problem that costs the healthcare system an estimated $60 billion a year at the lowest estimate, and perhaps as much as $200 billion a year, Simborg told an audience at the 3rd Annual Leadership Summit on The Road to Interoperability, held in Boston earlier this week.

Simborg chaired a follow-up panel that came up with a list of 14 specific recommendations that could be built into the review process used by the Certification Commission for Healthcare Information Technology.

"So what happened to our recommendations?" Simborg asked. "Well, it got a lot of push-back."

On some level, Simborg expected resistance. Requiring fraud protections would perhaps slow the already snail-like pace of EMR adoption - at 4 percent, compared with 90 percent in every other industrialized country, according to David Bates, MD, medical director at the Harvard University-affiliated Partners HealthCare in Boston.

"What I didn't expect was that (the Office of the National Coordinator) would totally drop fraud management from its plan," Simborg said. "What I can't understand is why we don't try to solve this problem."

"What I find astounding," said Reed Gelzer, MD, a member of CCHIT's privacy and compliance panel and co-founder of Advocates for Documentation Integrity and Compliance, "we are essentially suggesting our healthcare organizations adopt systems for which there are virtually no standards and minimal certifications. Where's the discussion of the fact that we are killing 50,000 to 100,000 people a year?"

Simborg, who has been a vocal supporter of EHR adoption for more than 30 years, is a co-founder and member of Health Level 7, a founding member of the American College of Medical Informatics and a board member of the Foundation on Research and Education at the American Health Information Management Association (AHIMA).

In his view, the focus on promoting adoption, which goes back to President George W. Bush's mention of electronic medical records in his State of the Union Address in 2004, might prove fruitless.

"Unless the focus changes," he said, "adoption of electronic health records will lead to higher healthcare costs without much benefit. Without proactive fraud management, whatever the problem is will be much greater in an electronic environment."

Beyond that, there are other issues.

The physician savings derived from electronic health records most often come from coding increases - what Simborg called "E&M code creep." The E&M stands for evaluation and management.

"We need to have fundamental changes in how we pay physicians," Simborg said.

While electronic health records provide a legitimate way for physicians to speed up their documentation, they also increase costs, he said.

He noted that when he developed a commercial EHR for oncologists, "our customers had an increase in billing that provided ROI in two years. More than half came from coding increases."

Simborg suggests that adoption per se is not the goal. "If driving value means slower adoption, that's OK," he said.

He recommends continuing "what we do right:"

  • Work on interoperability and certification;
  • Eliminate E&M payments based on volume of documentation;
  • Promote P4P models;
  • Build in decision-support and add incentives based on documented behavior change (over time, though, even that can be gamed, he said);
  • And tackle the issue of fraud management.

"Clearly we have to put fraud management in there somewhere," he said. "The elephant has to be slain."

"The issue is patient literacy," said Charles Jaffe, MD, chief executive officer of HL7. "When we put down our list of to-dos, let's make sure there are others in the equation besides providers."

Do you think healthcare IT leaders and the government need to re-focus their approach to electronic health record adoption? Send your comments to Editor Bernie Monegain at

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