Is your practice prepared for Y2K?
If you're not ready by July, experts say that it may be too late
From the April 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.
By Edward Martin
When Mason City Clinic in northern Iowa began having problems scheduling routine examinations for its oldest patients several years ago, few realized that the confusion was an omen of the technological trouble soon to follow.
Because the clinic's computerized scheduling software uses only two digits to record patient birth dates, a patient born in 1895 would be listed as being born in '95. The computer software assumed that the patient had been born in 1995—and scheduled pediatric exams for the clinic's centenarian patients.
The glitch was an early example of what has come to be known as the year 2000—or Y2K—bug, in which computer programs that abbreviate dates to two digits are expected to fail in the new millennium. As the clinic's physicians and administrators discovered, incorrect birth dates were just the tip of the iceberg.
"Among other things, we found that the city's municipal computers that monitor and control levels in the water tower that supplies us hadn't been made compliant," said Hal Hawkos, vice president for information systems at North Iowa Mercy Medical Center, which owns the clinic, a 350-bed hospital and 40 other clinics. Although remote, he said, "That raised the possibility that even our water supply could fail in January."
As the new century approaches, physicians and health care organizations around the country are trying to prevent worst-case scenarios where computers shut down critical biomedical equipment, cause elevators to freeze and disrupt power and communications. While experts say that such situations are unlikely, there is serious concern about the health care industry's ability to prepare for technological problems.
According to a recent report from the Senate Special Committee on the Year 2000 Technology Problem, health care is the least prepared to deal with Y2K problems. The report noted that only about 60% of hospitals were planning to test their Y2K fixes before the new year, making them vulnerable to any glitches that these fixes may cause.
But the Senate report contained an even more disturbing statistic: About 90% of physicians are completely unaware of how their offices may be affected by Y2K problems. In an industry that appears ill prepared to deal with Y2K issues, physicians rank dead last.
As recently as a year ago, much of the alarm about Y2K problems concerned infusion equipment, ventilators, defibrillators and other devices with date-sensitive computer chips that can seriously affect patient care. Experts fear that computers that cannot handle a change in date will freeze and simply stop working, causing havoc.
But the other part of the problem is that in health care, even seemingly innocuous glitches like wrong birth dates can have serious consequences. "In sophisticated monitoring systems, dosages are based on calculations that include age," said Donald J. Palmisano, MD, a New Orleans surgeon who heads the AMA's year 2000 initiatives. "If you didn't override that, you could be giving pediatric dosages to someone 100 years old."
With large health care organizations spending millions to address Y2K problems, some of those concerns are slowly abating. "There was a lot of doom and gloom about medical equipment, but we found most things worked just fine," said Mr. Hawkos from North Iowa Mercy. "There might be a few of what we call 'workarounds,' such as printouts that read '00' instead of '2000,' but that doesn't mean the equipment won't function properly."
Even large government agencies like HCFA say they will be ready for the new millennium. A year ago, many were predicting the Y2K problem would cause the collapse of the agency and its network of 78 outside contractors, which depend on computers to process physician payments. But by March, said HCFA spokesman Peter Ashkenz, 70% of those external systems had already been declared compliant, along with all of HCFA's 25 internal programs. "We will be ready on time," said Nancy-Ann DeParle, HCFA's administrator. "The question is, will doctors?"
For now, the answer seems to be a firm "no." Even before the latest report from the Senate committee, analysts had identified health care as an industry that was lagging behind in its Y2K efforts. Kenneth Kleinberg, health care research director at the Gartner Group Inc., an information technology research firm in Stamford, Conn., said that on a scale of one to five, industries like banking have largely completed Y2K preparations and are at a four or five. In surveys of the health care industry, however, he said that most physicians were in stage one or two of preparations, which meant they had not recognized the problem or even begun addressing it.
For physicians, a critical factor in addressing Y2K issues is cost. Even a solo practitioner with just a server and a few personal computer terminals might expect to pay $15,000 to $30,000 to update or acquire new practice-management programs and hardware. For larger practices, those costs can go much higher.
But analysts say that physicians who don't pay now will certainly pay later. That's because without a Y2K-compliant system, most physicians will be unable to bill payers and receive reimbursements.
Dr. Palmisano experienced just such a situation when his Medicare claims processor tried to update its computers for the year 2000. A number of physicians in Louisiana and Arkansas found their cash flow disrupted for up to six weeks. "We had to scramble to cover payroll and purchase supplies," Dr. Palmisano said.
Similarly, Y2K problems can potentially cripple physicians financially, explained Nicollete Francey, MD, a Greenwich, Conn., internist whose firm, Corporate Wellness Management Inc., helps practices determine if vendors and others are ready. "This whole thing could turn out to be a small bump in the road, or a huge disaster," she said. "I'm concerned it could be the latter, particularly for practices under pressure from health maintenance organizations and struggling to survive."
The time factor
The costs of preparing for the year 2000 are only part of the puzzle facing physicians. Time—and the lack of it—may turn out to be physicians' biggest enemy in making office systems Y2K compliant.
Consider the schedule that large health care organizations are following. In Iowa, for example, Mr. Hawkos said that high-risk technology—EKGs and heart monitors, for example—will be corrected and tested by June. Medium-risk items vital to finances will be tested by September or October, and low-risk items such as fax machines that merely date documents may remain uncorrected.
Because they have fewer resources to throw at the problem, physicians should probably be somewhat ahead of that schedule. "Everything should be in place, tested and completed by July, and if not, you're in a danger zone," said Mr. Kleinberg from the Gartner Group.
The bad news is that if you have already delayed too long, full compliance may be impossible. "At this point, we're in the administrative equivalent of medical triage," added Phillip L. O'Neill, a trial lawyer who represents physicians at the Washington law firm of Jackson & Campbell.
Even if you can't reach full compliance, you still need to get started. For physicians in smaller organizations, experts say that a good starting point is hardware such as network servers, desktop computers, laptops and handheld devices like PalmPilot computers used to store patient charts for rounds.
Michael Mieure, Y2K project manager for Medic Computer Inc., a Raleigh, N.C., vendor of practice management software, said physicians should examine their computers' internal clocks. "Software won't run if you can't boot up," he said. BIOS, the basic input-output system that controls disk drives, carries dates that can crash computers. Mr. Mieure suggested downloading diagnostic programs from manufacturers' Internet sites to check your computer.
Some diagnostic tests can be simple, although experts emphasize that you should back up files and data in case you trigger a system crash. "Create a dummy charge for a date after the year 2000 and see what your system does with it," suggested Roger A. Hofford, MD, a pediatrician in Lynchburg, Va., who is on the technology committee of the Medical Society of Virginia.
A number of Web sites also suggest advancing your computer's internal clock to the year 2000 to gauge its readiness for the new millennium. A number of experts, however, say this is a terrible idea. They warn that such a test can trigger a disastrous crash from which your computer may not be able to recover. It may be impossible to reset the machine's date once it has crashed, and if the computer is on a network, it could possibly damage other machines.
Keep in mind that not all hardware problems will occur in computers. Security alarms, heating and ventilating systems and components of telephone systems like private branch exchanges—known as PBXs—contain microchips with embedded dates.
Because not all problems will be limited to your office, an external checklist is equally critical. Check with oxygen, pharmaceutical and general medical suppliers to make sure that their systems are Y2K complaint. If an admitting hospital's compliance is in doubt, it might be prudent to arrange to admit patients to an alternate hospital.
The biggest threat
For most physicians, however, the biggest Y2K threat will come not from some outside system, but instead from their own practice management software. To determine your vulnerability, experts say, you and your practice managers should create a checklist of programs that handle functions like insurance processing, downloading data from medical devices, pharmacy inventories, plus staff scheduling, benefit and tax records.
When it comes to making your software Y2K compliant, there are three choices: completely replacing hardware and software; installing upgrades or "patches," special programs offered by software makers specifically for Y2K problems; or employing a consultant or programmer to tailor custom solutions.
The problem with the first option—a new system—is that it is costly. "An eight-doctor practice that has used the same practice-management and billing and accounts receivable system for five or six years might have to spend $50,000 to $100,000 for new hardware and software," said Rosemarie Nelson, a healthcare technology consultant with Health Care Data Systems Inc. in DeWitt, N.Y.
Time is another major hurdle in getting a new system before the new millennium. Physicians want to make sure they're getting the right system, but anyone just getting started will lack the time to be thorough. "They need to move ahead and not get caught in the paralysis of analysis," said Ms. Nelson. "You have to spend $50,000, so you try so hard to do the right thing that you do nothing."
The second option, an upgrade or patch, is a good one if your vendor is making such tools available. In addition, upgrades might come at little or no cost if the program is relatively new and the doctor has a service agreement with the vendor.
Scott H. Stewart, ACP-ASIM Member, a general internist in Auburn, Maine, handles billing, accounting, receivables and internal payroll accounting with a practice package called Medicine PM. While the program isn't yet year 2000 compliant, his office staff is waiting for the vendor to create a fix sometime this spring.
Experts warn, however, that physicians who wait until the last minute for their vendor to come through may discover that no such product exists. "The doctor who feels that because he laid his money out and is paying a maintenance contract he's automatically covered is in for a rude awakening," noted Mr. Kleinberg.
Costs for these fixes vary and have led to a number of lawsuits. In one instance, physicians who paid dearly for new software from Medical Manager Inc. sued when they learned that they would have to pay to make the product Y2K compliant.
New Jersey obstetrician Robert Courtney, DO, said he paid $20,000 for Medical Manager software in 1996 but then quickly learned that it was not year 2000 compliant. He and a group of 15,000 other physicians won a lawsuit alleging that Medical Manager used Y2K as a ploy to charge $100 million for fixes.
Other physicians have found the third option—consultants—another source of help. John H. Sipple, FACP, a pulmonologist in Syracuse, N.Y., has used a program called DataEase to store patient summaries since 1984. To make sure that the software will continue to function in the new millennium, his group, Internist Associates of Central New York, contracted with Health Care Data to supervise its Y2K compliance.
Experts warn that as January approaches, the potential for price gouging will grow. Mr. Kleinberg said that consulting rates have already increased 50% between early 1997 and the end of 1998 as competition between banking, health care and other industries drove up demand. "Overall, $100 an hour is not an unreasonable rate for consultants," Mr. Kleinberg said, noting that many programmers make two to three times that amount.
"Installing new hardware might take a week or two, and it could take another week to two weeks to replace practice management software, with total costs of $500 to $1,000 a day," Mr. Kleinberg said. "The whole process can run $15,000 to $20,000 for a small practice, not including the cost of hardware."
While the prices may seem prohibitive, most experts caution that any extensive Y2K compliance effort is best left to professionals. "If you have a small organization without an information systems manager, you probably shouldn't attempt to tackle the issue by yourself," Mr. Kleinberg said.
No matter which option you choose, if you wait too long you might have to resort to a more basic approach. "That can mean going back to your old, manual world of scheduling books and paper claims," said Ms. Nelson from Health Care Data Systems.
In North Carolina, problems arose in 1998 when gastroenterologist Michael Gaspari, MD, one of 11 doctors at the Charlotte Clinic for Gastrointestinal and Liver Disease, attempted to schedule colonoscopies for the new millennium. "Our computer started saying, 'There's no such date,' " explained clinic manager Ellen Calloway.
To deal with the problem, she set up a separate computer system until the clinic's Medic software was updated. The glitch was resolved and the clinic is now ready for the new century.
Procrastinators may find they have to resort to a similar solution: using generic business software and spreadsheets to run their offices. Such software generally goes for $3,000 or less, can be installed quickly and will do a basic job of tracking payments and scheduling appointment. Experts say, however, that physicians should not expect too much from these systems.
Finally, analysts say that not all Y2K contingency measures involve computers. Here is a sampling of strategies some experts suggest to prepare for year 2000 problems:
- By September, you should increase your available credit. "It is not uncommon for a third of a practice's money to come from the local Blue Cross plan and a third from Medicare. Can your practice survive a blip in their systems?" asked Ms. Nelson.
- Investigate backup power. Many practices already have uninterruptible power sources, and hospitals and some large clinics have permanent diesel generators for sustained operations in blackouts. Those systems are beyond the financial reach of most practices, but uninterruptible power systems for less than $2,000 can maintain computers long enough to shut them down without data loss if power fails.
- Practices that don't already archive and store patient and financial records off site should begin. Before year end, Mr. O'Neill, the Washington attorney, recommended that physicians and employees check pension and 401 (k) statements for accuracy, and file their own paper copies. Administrators, if possible, should compile payroll, W-2 and other data before the end of December.
- Physicians should avoid scheduling vacations from late December through early January, and managers should arrange for on-call physicians to remain in a single location during the critical New Year's period, in case paging and other communications systems go down. Some hospitals plan to limit elective surgery, and physicians should take it upon themselves to avoid scheduling it.
The underlying message from experts, however, is simple: Physicians need to take action now, not later. "We're not striking a panic tone, but doctors should deal with this just like any other crisis," said Dr. Palmisano. "If patients come in bleeding, we do what's necessary to resuscitate them, stabilize them, find the cause and fix the problem. We should face Y2K just like any ill patient."
Edward Martin is a freelance writer in Charlotte, N.C.
Making the Y2K diagnosis: Web sites and other resources
While most analysts recommend that physicians obtain outside help from consultants, there are a number of resources and diagnostic tests that you can use to gauge the extent of your Y2K problems.
Professional societies like ACP-ASIM offer a number of resources, and other nonprofit organizations have been created specifically to deal with Y2K issues. And if you're technically inclined, a number of vendor Web sites provide Y2K information on their hardware and software products.
Here is a list of some of the resources available to physicians:
- ACP-ASIM has a Y2K section that features an information packet on how to evaluate and select practice management and electronic records software. The site also offers a Y2K compliance tool kit with inquiry letters to send to vendors and software to test for Y2K problems.
In addition, the College will hold a Y2K workshop at this year's Annual Session. "The Year 2000 Problem: Preparing Your Practice's Information Systems" will give internists tips on how to minimize the impact of Y2K problems on their hardware and software. For more information, see the Annual Session final program.
- The AMA's Y2K home page offers articles about year 2000 issues, a list of frequently asked questions and suggestions for detecting compliance problems. Much of the material is available to members only.
- The FDA's site offers detailed information the compliance status of all kinds of biomedical devices.
- The CDC contains general information on Y2K issues and details about its own compliance activities.
- HCFA contains information on how Y2K issues will affect Medicare and Medicaid patients and providers.
- Microsoft Year 2000 Readiness Disclosure & Resource Center offers a newsgroup to talk about Y2K issues and lists of Microsoft year 2000 products and resources.
- Rx2000 is a Minnesota-based nonprofit group developing solutions to Y2K issues. Its Web site offers a schedule of its seminars, as well as a discussion group, articles, links to other sources and a speaker's bureau.
- Greenwhich Mean Time sells tools to detect and diagnose Y2K problems on PCs. The site also sells educational videotapes on the topic.
- Year 2000 offers a collection of news articles and links to Y2K consultants and vendors.
Limiting your liability for year 2000 mishaps
While the year 2000 problem is widely viewed as a technology issue, physicians should also consider it a serious liability concern. If patients are harmed by a Y2K mishap, experts say, they will likely come after you for damages. Here are some safeguards.
Donald J. Palmisano, MD, an AMA trustee who is heading the organization's year 2000 initiatives, said that a good place to start is to contact your malpractice insurers. Ask if their policies cover you if patients are injured by a Y2K failure. Many policies consider Y2K as an avoidable threat, not an accident, and don't cover Y2K-related problems.
Dr. Palmisano cited several examples from more than 450 software-based equipment failures since 1986 as types of problems that might become more likely when the new year arrives: He pointed to one instance in which a radiation therapy machine gave excessive dosages to six patients, resulting in three deaths. Other more common technological glitches include heart monitor breakdowns and ventilators that cause comatose patients to take too many breaths.
In many of these instances, everyone including doctors, vendors, equipment makers and maintenance companies were dragged into lawsuits. "Doctors could bear the brunt of Y2K liability," Dr. Palmisano added. "People filing claims will look for deep pockets and attempt to get as many people as possible involved."
For that reason, Dr. Palmisano said, the AMA has been fighting an attempt in Congress by biomedical equipment makers to limit their liability in exchange for divulging problems with their equipment. Several legal sources noted that physicians, as owners and end-users of equipment, are likely to be held ultimately responsible for its proper and safe use.
To protect yourself, experts say, you should keep detailed records. "It's important to document all inquiries to software and equipment makers, vendors, suppliers, utility companies and everyone else," said Phillip L. O'Neill, health care attorney with the Washington, D.C., law firm of Jackson & Campbell. "This can be as simple as writing a letter, or at least keeping a log of telephone conversations with names and dates. It's true that an office manager can testify, but human memory can be a frail thing."
Finally, there is an even more basic reason to document your Y2K compliance efforts. Corporations, hospitals, health plans and others will increasingly refuse to do business with practices that can't certify compliance.
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