Progress Illinois

Four years ago, the Chicago Department of Public Health (CDPH) issued a massive report titled Strategic Plan 2006-2011. Hoping to maximize dwindling resources, administrators laid out a detailed plan for how CDPH should reorganize internally to provide the best care possible to its patients. One of its stated goals was to "[e]stablish streamlined, user-friendly administrative support structures." As reporter Alex Parker lays out in his blistering exclusive for the Chi-Town Daily News, a new billing system implemented by the city last year clearly didn't meet this objective. Due to the resulting problems, four South Side mental health clinics had been scheduled for closure today.  Possibly as a result of Parker's reporting (as well as yesterday's sit-in), Mayor Daley halted that plan at the very last minute this afternoon and stated his intention "to find out some of the issues there."

So what are the "issues" in question?  Here's a rundown of what we know.

Earlier this year, CDPH announced that the four of Chicago's twelve clinics would be closed thanks to the state cutting the city's mental health funding by $1.2 million.  Mayor Daley tried to cast aside responsibility for the closures, saying that the state was to blame.  But Springfield pushed back, disclosing that the city had failed to bill them for certain services during FY 2008.  Because the state's current-year payments are based on previous reimbursements for services, this resulted in the funding adjustment. 

Up until today, this underlying billing problem had been referred to as a "glitch" or "malfunction" -- with few additional details. The Chi-Town Daily News article finally fleshes things out.

According to the documents Parker obtained through the Freedom of Information Act, the so-called "glitch" wasn't some isolated incident that the department quickly identified and resolved. Rather, CDPH's new computerized billing system, designed by the health care technology provider Cerner, "was so flawed that patient bills weren’t submitted to the state for six months in 2008."

Parker further reports that state officials were concerned from the very beginning that the city's plan to switch to the Cerner software in February of last year might cause problems. "March 1st [2008] is right around the corner," wrote Peggy Peterson, the chief DHS liaison to the city's public health department in a February 22 letter, "and if the software is not programmed to work correctly with Springfield’s system, claims and service reporting will not be accepted." The city went ahead with the plan anyway, and problems ensued:

On April 29, Peterson warned, “I can not stress enough the importance of continued and timely submission to DMH of all FY08 service reporting and billing via whatever software is functional.” 

In the same email, she noted that the state began reducing monthly allocations based on billing in January, docking 10 percent of CDPH’s monthly service stipend, and would continue doing so if billing did not reach 100 percent. The city, she said, could risk more than $334,000 if it did not resolve its billing issues.

In June, Peterson wrote that the state had received no billing since mid-March, shortly after the city began using the new system. A city official replied that the Department of Public Health and Cerner were working to fix the problems.

On June 9, Peterson again recommended that the city return to billing with the state system. She noted that the state had already docked the city $334,059 since February. 

The next day, Mason wrote to DHS officials saying the transition to the Cerner system “to date, has been unsuccessful.” He said the city could not use the state system or manually submit bills because all of the city’s patient information resided in the new computer system.

Of the 14,261 claims eventually submitted to the state, a whopping 95 percent were rejected for missing data.

That's a lot of mistakes, particularly considering how much the Cerner system has cost taxpayers. According to the company's vendor contract (PDF) from January 2007, the city awarded the company up to $16.1 million to implement its Clinic Practice Management Information System. Cerner has already pocketed more than $10 million for their work, which will run through 2012.

We should note that the growing use of electronic medical records is an encouraging development.  When implemented appropriately, such systems can increase the quality of care and lower its cost.  Cerner is apparently a leader in providing these services, having specialized for 25 years in helping hospitals and doctors digitize their day-to-day clinical work.

But as the CPDH implementation shows, their technology is flawed and wreaking havoc as a result.  Indeed, Chicago isn't the only government body having trouble with the company's software.  The head of the IT program for Britain's National Health Service (NHS) said in late 2007 that he was ashamed of the quality of some of the systems implemented by Cerner:

In December 2005 Nuffield Orthopaedic Centre became the first NHS site to go live with Cerner Millennium under the NHS IT programme. It has since suffered a string of problems ranging from missing appointment records, to inability to report on wait times. The Millennium system – now installed at six NHS locations in the South – remains unable to directly integrate with Choose and Book or meet 18-week reporting requirements.

As a result of their concerns, NHS disclosed last month that it is reaching out to other technology providers in case the Cerner programs don't improve in the next few months. 

How could companies like Cerner improve their product?  A recent piece published in the New England Journal of Medicine stressed the need for these providers to begin using open-source software to allow for more flexibility and innovation.  From the New York Times:

In the article, identified as a “perspective,” Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane portray the current health record suppliers as offering pre-Internet era software — costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements.

Instead of stimulating use of such software, they say, the government should be a rule-setting referee to encourage the development of an open software platform on which innovators could write electronic health record applications. [...]

Such an approach, they say, would open the door to competition, flexibility and lower costs — and thus, better health care in the long run. “If the government’s money goes to cement the current technology in place,” Dr. Mandl said in an interview, “we will have a very hard time innovating in health care reform.

But while Cerner has plenty of room for improvement, CDPH is the one who deserves the blame in this case.  After all, they chose to the contract with the company and, as Parker's reporting shows, ignored warnings from Springfield prior to implementation (even as the British were complaining publicly about their problems with the system). 

This isn't the only costly embarassment on CDPH's docket this year.  In February, the city's inspector general found that nearly $1 million in drugs and medical supplies were spoiled or unaccounted for in a CDPH warehouse, in part because of poor record-keeping.

Meanwhile, Health Commissioner Dr. Terry Mason isn't the only city official who has recently overseen a botched technical transition.  The Sun-Times reported in late March that "stacked-up calls to Chicago's 911 emergency center are 'disappearing completely' from computer screens because of glitches in a $6 million upgrade to the dispatch system."

So what's the current status of the CDPH billing system?  Department spokesperson Tim Hadic tells us over email that they have been "working collaboratively with the state for months to work to get the systems in sync." As of several weeks ago, the billing data apparently started to flow.  This apparently means that state funding will return to proper levels in approximately 18 months.  As AFSCME Council 31 spokesperson Anders Lindall pointed out in March, in order to keep the four clinics open the city simply simply needs to find the money to fill this temporary gap.  Considering the millions in taxpayer dollars going to downtown parks and corporate headquarters, this shouldn't be too hard.

Mayor Daley took a positive step by calling off the closures today.  Hopefully, he'll go on to see that the vulnerable residents who depend on these facilities don't deserve to be punished for the mistakes documented above.