COVID-19 revealed how sick the US health care delivery system really is
If you got the COVID-19 shot, you likely received a little paper card that shows you’ve been vaccinated. Make sure you keep that card in a safe place. There is no coordinated way to share information about who has been vaccinated and who has not.
That is just one of the glaring flaws that COVID-19 has revealed about the U.S. health care system: It does not share health information well. Coordination between public health agencies and medical providers is lacking. Technical and regulatory restrictions impede use of digital technologies. To put it bluntly, our health care delivery system is failing patients. Prolonged disputes about the Affordable Care Act and rising health care costs have done little to help; the problems go beyond insurance and access.
I have spent most of my career within the domain of information technology and IT-based innovation and systems engineering. As a professor of health informatics, I have focused on health care transformation. For two years, I served on the Health Innovation Committee at HIMSS, the preeminent global health information and technology organization. In short, I have studied these problems for decades, and I can tell you that most of them aren’t about medicine or technology. Rather, they are about the inability of our delivery system to meet the evolving needs of patients.
In reality, the U.S. health care sector is not a system at all. Instead, it is an underperforming conglomerate of independent entities: hospitals, clinics, community health and urgent care centers, individual practitioners, small group practices, pharmacy and retail outlets, and more, most of which compete for profits and in some cases pay sky-high salaries to executives.
These entities often function in silos. Errors, gaps, duplication of services and poor patient outcomes are often the result.
Here’s an example: A heart surgery patient, still on oxygen and in intensive care just two days earlier, is referred to her primary care physician for follow-up, and to a rehabilitation center for therapy. Neither her doctor nor the facility knows the patient was even hospitalized, nor do they have access to her records or medication list.
Shopping for doctors
For patients, this might mean a disjointed set of services that don’t offer a coordinated plan of care or even a timely or comprehensive diagnosis of their health problems. Patients with chronic conditions often see more than 10 different doctors during dozens of office visits per year.
The specialist may not even be aware when the patient does not return. Patient information is seldom shared; specialists are often associated with different medical systems that don’t share records. And even when they try, accurately matching patient IDs in different systems can be problematic.
The challenge now is to transform the status quo into a high-performance system, a true 21st-century health care delivery system. Bringing systems engineering and information technologies to medical practice can help make that happen, but doing that requires a holistic approach.
Let’s start with electronic health records. More than 20 years ago, the Institute of Medicine called for the transition from paper to digital health records. This would allow patients to easily share lab, imaging and other test results with different providers. Nearly a decade went by before action occurred on the recommendation. In 2009, the HITECH Act was passed, which provided US$30 billion of incentives for the transition.
Yet now, 12 years down the road, we’re still a long way from a patient’s electronic health records becoming universally available at the point of care. Connectivity across systems and networks remains fragmented, and a lack of trust between organizations, along with anti-competitive behavior, results in an unwillingness to share patient information.
Unsafe medical treatment
One failure of the system is an inability to accurately identify and match patient records. Few standards exist for collecting patient information. With hundreds of vendors and thousands of hospitals, doctor’s offices, pharmacies and other facilities participating in the process, variation is huge. Is John Doe at 250 Park Ridge Drive the same as John E. Doe at 250 Parkridge?
In 2017, the American Hospital Association estimated 45% of large hospitals reported difficulties in correctly identifying patients across information technology systems. This means, on occasions at least, clinicians are making decisions that lead to increased chances of misdiagnosis, unsafe medical treatment and duplicate testing.
During a public health emergency like COVID-19, accurate ID’s of patients is one of the most difficult operational issues that a hospital faces. Accurate COVID-19 test results are hampered when specimens, sent to public health labs, are accompanied by patient misidentification and inadequate demographic data. Results can be sent to the wrong patient, or at best, get backlogged.
These mistakes also are costly. More than one-third of all denied claims result directly from inaccurate patient identification or information that’s wrong or incomplete. This costs the average U.S. health care facility $1.2 million per year.
Congress needs to act
For nearly two decades, the Department of Health and Human Services has been restricted from spending federal dollars to adopt a unique health identifier for patients. To remedy the problem, the U.S. House of Representatives in July 2020 unanimously adopted an amendment allowing HHS to evaluate patient identification solutions that still protect patient privacy. But the Senate chose not to address the issue. Still, many health care leaders are advocating for the new Congress to take action. Health care proponents are hopeful the new Senate majority leader will be more receptive to addressing the issue.
A bright spot in all of this is that many health care systems saw the advantages of telemedicine during the pandemic. It’s convenient for patients, it saves money and it meets the needs of patients who have difficulty traveling. Telemedicine could be just the beginning; with an ever-growing array of mobile health devices, physicians can monitor a patient at home, rather than in an institution. More must be done, however. Throughout the pandemic, some patients, with a lack of broadband access or poor Wi-Fi, had something less than a rich and uninterrupted visit.
Black Lives Matter makes clear need for expungement reform
On July 9, NJ.com reported on the struggle of New Jersey resident Kenneth Jones, whose efforts to clear his criminal record have been stymied by a backlog in the New Jersey courts that has been exacerbated by the coronavirus. The then-14-month delay has inhibited his ability to get a better job or find more suitable housing.
His story is similar to that of many people of color and other minorities in New Jersey and nationwide. Support for the Black Lives Matter movement has surged in recent months, leading to talk of defunding or radically reforming policing. But these measures won’t repair the damage already done to many minorities who suffer under the stigma of a criminal record, which in thousands of cases exists solely due to one-time offenses for petty crimes and misdemeanors. These criminal records can not only scar one’s self-esteem, but also create barriers that impede basic opportunities to advance in society, including employment, housing, education and more. To fix this will require serious expungement reform, and New Jersey can lead the charge.
Forty-two states in the United States allow individuals to seal or “expunge” their criminal records. Yet very few take advantage of this. As recently as late 2019, New Jersey passed new laws making the expungement process easier. Some lucky individuals could have their record cleared after only three years. But even three years can seem like a lifetime if one cannot find employment or safe and affordable housing.
Even worse, three years is a best-case scenario — five or six years are more common. And this is assuming that everything goes smoothly. Remember, New Jersey’s expungement process is suffering from a major backlog caused by outdated systems and coronavirus-induced staffing challenges.
Delays extend punishment
A comprehensive study by Rosenblum Law of New Jersey reveals that New Jersey is not the easiest state when it comes to having one’s criminal record expunged. The fact remains that any kind of waiting period is a de facto additional jail sentence for those individuals who often have only committed a low-level offense. While recent headlines have been all about police reform, true criminal justice must also include reasonable expungement laws.
Criminal records disproportionately impact the poor and people of color. According to the NAACP, African Americans are twice as likely to lose a job over the same convictions as whites. Two separate studies by the National Institute for Justice found that 17% of white Americans with convictions received callbacks for jobs, compared to 5% for African Americans. Overall, having a criminal record reduced the likelihood of getting a job by two-thirds for African Americans. The same studies also showed that Hispanic and Latino Americans suffered similar penalties for a criminal record. Ethnic disparities in the justice system are even more evident when we examine marijuana offenses and their impact on criminal records.
In addition to unfairly impacting these ethnic groups, expungement laws penalize the follies of youth. How many of us have made missteps when we were younger? Yet as we matured and looked back on our actions, we were able to acknowledge that we’d used poor judgment at the time and are now sincerely remorseful. New Jersey’s significant waiting period before records can be cleared ensures the record hangs over the heads of Black men and women far beyond the sentence.
Limiting job opportunities
Regardless of the crime and when it was committed, a criminal conviction of any kind can close doors on job opportunities. It can also limit housing and educational opportunities. According to the research from the advocacy group the Sentencing Project, more than 60% of formerly incarcerated individuals are still unemployed one year after release. Those who do manage to find jobs take home 40% less pay on average.
A closer look reveals that individuals who’ve successfully had their records expunged can turn their lives around. An article featured in the Harvard Law Review found that those who received expungements saw earnings increase by 20%, as unemployed persons found work and minimally employed persons landed steadier jobs.
Expunging records can also lower crime rates. Harvard University research shows that after age 26 people convicted of crimes are far less likely to commit another crime if they have at least full-time, minimum-wage jobs.
The vast majority of those who have served their time, as proven by multiple studies, are far less likely to commit additional crimes after receiving an expungement.
Since we all agree that Black Lives Matter, let’s not just pay lip service to the concept but act swiftly to remove one of the single greatest barriers to equal opportunity. We can help others get a clean start and sooner, by not only shining a light on the benefits of expungement but by lobbying politicians to make these long-overdue changes.
Adam H. Rosenblum is the founding attorney of Rosenblum Law, P.C., a general law practice with offices in Bloomfield, New Jersey, New York City, Albany and Buffalo.