Practice Fusion pushed opioids
January 29, 2020 3:55 AM   Subscribe

Practice Fusion, an electronic health record vendor will pay a $145 million fine as a result of receiving kickbacks for modifying their software to increase the prescription of opioids. Pharma Co. X, not yet identified in the DOJ agreement agreed to give Practice Fusion one million dollars to put a series of alerts in their software that would prompt doctors to ask patients about their pain levels more frequently and to favor opioids as a pain treatment option.

The talks between Practice Fusion and Pharma Co. X began with the intention of creating alerts that would help identify patients at risk of addiction but that plan was abandoned. According to the Guardian, Pharma Co. X is Purdue.

The DOJ settlement also resolves allegations that Practice Fusion falsely claimed that it's software met the requirements set by HHS for electronic health records software.
posted by rdr (35 comments total) 23 users marked this as a favorite
$145 million fine

Here is an idea, from another recent article, about a different pharma company:

“Not only is the company going to get fined an astronomical amount of money, which I’ve seen a million times, but worse case scenario, which I’ve never seen before, they might actually take my money.”
posted by thelonius at 4:06 AM on January 29 [6 favorites]

That was said by someone who was surprised and dismayed that he was going to jail. Let's do all three: fine companies, fine executives, and send executives to jail.
posted by jeoc at 4:17 AM on January 29 [34 favorites]

How about some wrongful death charges just to be clear.
posted by SaltySalticid at 5:13 AM on January 29 [22 favorites]

"...they might actually take my money.”

Which, when it's all said in done, is really the only way you'll ever curb such malevolent malfeasance; directly fine the executives. And include jail time.
posted by Thorzdad at 5:37 AM on January 29 [28 favorites]

Yep. Until governments start prosecuting executives & putting them in jail this kind of thing is just going to keep happening, because these characters don’t care about other people’s suffering & that includes the people they hurt directly and the people that pay the monetary cost in lost jobs & lost pensions. None of these people matter in any way to them - the only thing they care about is themselves & unless and until they perceive the potential for their own personal welfare to be negatively affected by their actions this stuff is going to happen again and again and again.
posted by pharm at 5:41 AM on January 29 [10 favorites]

Jail. Jail them all. And heck, take their homes too. Why? Because I’m sure a lot of addicts they helped make lost theirs, along with a lot more.
posted by Jubey at 5:42 AM on January 29 [22 favorites]

It's crazy that doctors get so mad online about patients googling their symptoms and questioning them as if they're these all powerful, all knowing, unquestionable medical science gods, meanwhile they're just reading instructions off a pop up and just doing whatever it says.

On the other hand, I can definitely understand seeing all these patients come in who need pain relief one after another and wanting to give them some relief. It's not like there's much of anything else they could prescribe instead.
posted by bleep at 6:04 AM on January 29 [30 favorites]

The irony that alerts meant as a possible way to help identify potential addicts morphed into a way to help create them represents a breathtaking level of greed. I knew that already but this telling detail is a particularly outrageous example. Jail time: I want execs to see more of it.
posted by Bella Donna at 6:21 AM on January 29 [6 favorites]

According to court filings, the rigged alerts popped up on doctors’ computers more than 230 million times between July 2016 and the spring of 2019, when criminal charges were filed. The health-care providers who received them prescribed extended-release opioids at a higher rate than those who didn’t, prosecutors say.

No kidding. The alerts were targeted at fresh meat, which is to say patients who had never received prescriptions for opioids before. (Insert The Scream face here.) WTF?! This latest mess was brought to you in part by big data, to meet all your addiction-creation needs.
posted by Bella Donna at 6:42 AM on January 29 [8 favorites]

$145 million fine The fine should be ruinous, they should not be allowed to continue in business, there should be criminal charges.
posted by theora55 at 6:46 AM on January 29 [21 favorites]

I've never used PracticeFusion, but in residency, we had Epic, whose default admission orders for inpatients included the following:
Mild pain (1-3): tylenol 650 mg
Moderate pain (4-6): oxycodone 5 mg
Severe pain (7-10): oxycodone 10 mg

These orders were auto-fill, meaning if an RN or CNA documented a given pain level, Pyxis would automatically dispense whatever the "appropriate" medication was. Don't remember what the pain assessment interval was, probably every 2 or 4 hours, which meant you got absurd situations like people getting woken up in the middle of the night to be asked about pain and given a crapton of oxycodone.

In theory, you could uncheck all those boxes and write your own pain orders, but (1) that's unlikely to happen when you've already been awake for 25 hours straight and (2) definitely not happening when you are cross-covering 50 or 60 patients overnight.

There may have been an auto-order to notify MD if severe pain reported 3 times in a row, or something? I recall getting paged to order potassium all the damn time; don't recall a single pain-related page. I do remember reading Jane Smiley's A Thousand Acres (1991) during my first year of residency (2012-2013) and being totally gobsmacked at the scene where a character goes to the ED after a farming accident and is given, like, 2 pills of oxycodone with a caution to use them sparingly. Our ED's pain discharge order set was 30 pills.

At the time there was a huge patient satisfaction push, at the health system and possibly national level, to call pain the "5th vital sign." Massive resentment from clinicians about that (particularly housestaff, who are primed to be resentful about everything), because we'd get people in our clinics who were addicted to pain meds (BECAUSE WE MADE THEM THAT WAY) and little to no resources to help them. I vividly recall seeing a patient in the ED who was desperate to detox, and we called every facility in the state, no one would take her unless I straight-up lied and said she was alcoholic. (Because while opioid withdrawal makes you feel like you are dying, alcohol withdrawal will actually kill you, so the state allocates some -- but not enough -- resources to it. But you know, then they'd just give her benzos instead, to prevent the fake-alcohol withdrawal, so ... not really helpful, in the long run.)

There's a lot written about pain undertreatment, especially among women and minorities, but the way to fix that isn't throwing more pills at people in the hopes they'll give you 5 stars on Yelp or Press-Ganey. What a perverse incentive system we've created in the US.
posted by basalganglia at 7:32 AM on January 29 [39 favorites]

These orders were auto-fill, meaning if an RN or CNA documented a given pain level, Pyxis would automatically dispense whatever the "appropriate" medication was.


10 mg of oxycodone was AUTOFILLED without an MD's supervision? Holy SHIT. Ten years ago, I was in horrible, crippling pain from a compressed disc, and presented at the emergency room reporting a 10 on the pain scale (I've had bone breaks hurt less than that). I'm 6'5", and not slight of frame. At no point in the ensuing 3+ years of pain treatment was I given 10mg of oxycodone, because that is an ABSURD amount of opioid, even for someone being treated for intense chronic pain.

Each and every one of these fuckers should be staring at prison sentences. Make the statutory minimum sentence equal to the longest sentence handed out to anyone who was subsequently arrested for opioid abuse after getting hooked on them.
posted by Mayor West at 7:46 AM on January 29 [6 favorites]

This was free, cloud based software. Unlike a system configured internally I'm not sure why a doctor would approach this with any particular degree of trust, and yet:
The drugs were even suggested for patients who didn’t experience severe pain, or who experienced isolated episodes of acute pain over several months but didn’t suffer from round-the-clock discomfort.
This is insane. The WP article says its unclear how the investigation began, but I hope it was because a lot of doctors saw this and knew it was horribly wrong and some reported it.

The fine at least was greater than the value of the company when it was sold to Allscripts, and it looks like the company despite initial hype was a net loss to investors. Of course some people still made millions.
posted by mark k at 8:05 AM on January 29 [2 favorites]

A relative was experiencing severe back pain from a spinal injury, and I don't think they went beyond 2.5 mg, and only if requested, and not always.
posted by RobotVoodooPower at 8:19 AM on January 29 [1 favorite]

A relative was experiencing severe back pain from a spinal injury, and I don't think they went beyond 2.5 mg, and only if requested, and not always.

My mother in law takes 10 mg of oxy multiple times daily for various elderly problems. I think she might actually take 2 of them at a time. My father in law takes 10mg twice a day for a case of shingles that he still has nerve pain from. Everyone in their 'elderly group' has a story like this.
posted by The_Vegetables at 8:27 AM on January 29

is this where we get the 100 comment derail with people not understanding the differences between oxycodone, oxymorphone, hydrocodone, hydromorphone, etc?
posted by ryanrs at 9:20 AM on January 29

If you have pain, in some cases you have two options:
1 - take a drug to reduce pain. Pros, probably covered by your insurance, doesn't take a lot of time, works fast. Cons, addiction risk, doesn't improve the underlying issue.
2 - see a physiotherapist (or similar). Pros, likely to improve the underlying issue, no addiction. Cons, costs a lot even if some is covered, takes a lot of time, doesn't fix it immediately.

People don't, as a rule, want to get addicted to meds. But all the incentives are towards medication as a solution to pain.
posted by jeather at 9:43 AM on January 29 [4 favorites]

> ryanrs: "is this where we get the 100 comment derail with people not understanding the differences between oxycodone, oxymorphone, hydrocodone, hydromorphone, etc?" Nice snark, but you could have posted a link and been informative. FTFY HAND
posted by theora55 at 9:52 AM on January 29 [3 favorites]

Pierce the corporate veil. Any time a corporation is found guilty of a crime, the complete chain of executives should also be held directly accountable.
posted by tclark at 10:17 AM on January 29 [7 favorites]

To recap:

Allscripts (market cap $1.5 billion) paid $100 million in cash for Practice Fusion in 2018, and now has to pay an extra $145 million in fines, for a total cost to Allscripts of ... $245 million.

Just seven months before that, in 2017, Allscripts intended to pay between $225 million and$250 million for the company, but somehow figured out there might be something hinky/expensive going on (w/r/t Practice Fusion itself or the sector in general) and negotiated the lower price.

a) Allscripts bought the Practice Fusion at the price they originally wanted and now have a magic get-out-of-jail card from the DOJ

b) The guilty parties who sold Practice Fusion cashed out for $100 million and face no further criminal or civil liabilities

Did I get that right?
posted by jcrcarter at 10:27 AM on January 29 [16 favorites]

Just a reminder that this type of corruption has its root in the monopoly patent system that makes otherwise cheap drugs worth billions of dollars. If there weren't billions involved, they wouldn't have the incentives to commit crimes and pay bribes for advertising and dispensing.

Americans pay 10 or 100 or 1000 times as much for their drugs as in other countries. That's a lot of loot to fund corruption.
posted by JackFlash at 10:48 AM on January 29 [12 favorites]

Silly commenters - Len Bias laws only apply to poor non-CEO drug dealers. If you own an LLC, you're safe! (sorry, wrong sport, I guess).
posted by symbioid at 11:22 AM on January 29

Actually wrong laws, too. nevermind.
posted by symbioid at 11:23 AM on January 29

But all the incentives are towards medication as a solution to pain.

True, although sometimes you can go through every option of #2 and still end up with medication as the only solution (true for me --- I have no issues with access to care, there's just nothing they can do about it after 20 years of trying). Of course, now that medication access is being taken away, you're left with #0: just suffer pain.
posted by thefoxgod at 12:01 PM on January 29 [11 favorites]

@JackFlah: According to the Tech Crunch article inestors put hundreds of millions into Practice Fusion so in aggregate the owners at the time of th wrong doing lost money.

The losses are of course not distibuted according to level of guilt but it's at least not some massive profit accross the board.
posted by mark k at 12:55 PM on January 29

It's almost as if there's something profoundly wrong and corrupt with the practice of capitalism in the United States. huh.
posted by theora55 at 1:58 PM on January 29 [6 favorites]

Just a reminder that this type of corruption has its root in the monopoly patent system that makes otherwise cheap drugs worth billions of dollars

Well, as someone else pointed out up thread, the doctrine of the corporate veil is doing a lot of work here. Take away the magical liability shield and I bet behavior changes.
posted by PMdixon at 3:12 PM on January 29 [3 favorites]

Jail. Jail them all.

I have a much better idea, but it involves cloning a T-Rex, if anyone out there is ripe for the enterprise.

We can make a mint in a sold out stadium selling hotdogs pressed into a human shape, in a hotdog bun shaped like a business suit.
posted by CynicalKnight at 4:31 PM on January 29 [2 favorites]

What we need is more research into medications that treat pain without also ruining lives. My husband has suffered from chronic pain for years that physical therapy only made worse, surgery wasn't covered by insurance for a long time just because they didn't want to shell out the money, and now he can't get it done because they've closed most of the hospitals and he's on oxygen so the doctors around here feel he's too medically complex for the facilities they have. Because his kidneys have failed he can't take over the counter meds, which are really hard on the body over the long term. Patients are left with nothing to treat their pain. And yes pain IS a vital sign - it's the signal your body gives you that something is wrong. Doctors are starting to forget that now that there's no way to treat it anymore because it's psychologically too hard for them to deal with.
posted by bleep at 4:38 PM on January 29 [9 favorites]

bleep, I'm so sorry about your husband. That sounds awful for him to have to deal with, and for you to have to watch..

You're right that watching someone suffer is probably the worst thing, psychologically, that doctors and nurses do. Even more so when the suffering is our fault. Over-reliance on painkillers (OTC as well as prescription) is exactly what got us into this mess. I've seen good data supporting things like comprehensive pain clinics, biofeedback, etc -- with the caveat that it may not be the right answer for all patients, but it may at least help subacute pain before it becomes chronic pain. Those centers are massively underfunded and understaffed, though, because the incentive for the last 25+ years has been in favor of drugs.

I'll push back gently that pain is NOT a vital sign. It's important but it's not objective -- it's probably the most subjective thing on the planet. Your "8" is probably different from my "8" -- it's not even clear that my "8" is the same from day to day. (The other vital signs, for anyone not familiar with that term, are temperature, blood pressure, pulse, and respiratory rate. Objective, countable things. Note that even height and weight are not on that list. But pain is?)

As a neurologist -- albeit not a pain specialist -- I care a lot more about the quality of someone's pain (sharp, stabbing, throbbing, itching, achy, tingling) because that tells me about cause and possible treatment, rather than some semi-arbitrary scale that was developed to test the benefits of opioids.
posted by basalganglia at 5:12 PM on January 29 [5 favorites]

Just as an aside, my impression as someone who sees medical records after things have gone wrong is if anything it's oxygen saturation that has become a de facto 'fifth vital sign.'

I hadn't realized the way these default care orders work in Epic and the like. Practice Fusion and Purdue colluding is even worse, but if Epic is doing it this seems like a significantly underreported aspect of the opioid crisis.

I really appreciate basalganglia's insights. Maybe slartybartfast and herrdoktor will drop in too, they've had interesting things to say about how orders are generated in Epic in at least one old thread.
posted by snuffleupagus at 2:48 AM on January 30 [1 favorite]

Maybe everybody realizes this, but basalganglia was taking about inpatient orrders in Epic. Would receiving higher doses of opioidsas part of a brief inpatient stay cause addiction?
posted by jeoc at 3:37 AM on January 30

I think each institution sets their own order sets when they contract with Epic.

Bigger picture, this story is truly horrifying (jail? Send these execs to the fucking guillotine) but I think it should lead more broadly to some critical thinking about the move toward automated medicine.

There are a lot of benefits of the Epic style, with built in algorithms to aid decision making. But this really points to the dangers of any automated reminder system, even if not programmed with corruption in mind.

I'm not sure I can fully form my thoughts on this ...
posted by latkes at 5:24 PM on January 30 [2 favorites]

I'm not sure I can fully form my thoughts on this ...

Mine in the direction I take you to be pointing go something like "unless we have a relatively coherent notion of where electronic medical record systems are intended to replace a clinician's judgment and where inform it, they're going to just be another source of Procrustean noise in the system."
posted by PMdixon at 5:28 AM on January 31

My thesis for a while now is that the adoption of electronic health records (EHRs) has been more about control of physicians than empowering them. If I ever get around to writing the monograph on this, instances like this with Practice Fusion will be primary evidence.

Why is it typically so hard for physician-users to modify the EHR environment to increase the efficiency of their workflow but considered value-added to obtrusively add "best practice advisories," "quality metrics," and treatment suggestions from above with little evidence for their effectiveness?
posted by adoarns at 6:04 AM on January 31 [4 favorites]

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