‘Black hole’ of medical records contributes to deaths, mistreatment at the border

December 1, 2019

The Department of Homeland Security’s inadequate medical technology and record-management for the thousands of migrants who pass through its custody are contributing to poor care and even deaths, according to lawsuit records reviewed by POLITICO.

A review by POLITICO of 22 deaths of detainees in Immigration and Customs Enforcement custody between 2013 and 2018 revealed malfunctioning software and troubling gaps in use of technology, such as failure to properly document patient care or scribbling documentation in the margins of forms. Those reviews echo persistent complaints from experts and advocates for migrants rights who say attention to the medical needs of asylum seekers is indifferent at best. Recent reports indicate that Customs and Border Patrol rejected a CDC recommendation to administer flu shots to people in its custody; two children later died of flu in the agency’s facilities.

“You can’t take proper care of patients if you don’t document care,” said Stan Huff, chief medical informatics officer at Intermountain Healthcare in Utah, who reviewed the paper trail of many of the deaths for POLITICO.

The publicly released death records are cited in a lawsuit brought by the Southern Poverty Law Center and others in August that alleges that ICE’s “centralized policies, practices, and failures of meaningful oversight” have led to unnecessary death and suffering.

Patients suffer from “delays in medical care, refusals to accommodate disabilities, and nearly constant isolation,” according to the suit. “Conditions in detention are so brutal that many people are forced to abandon viable claims for immigration relief and accept deportation out of a desperate desire to escape the torture they are enduring in detention on U.S. soil.”

It cites ICE’s handling of Hamida Ali, a 28-year-old asylum seeker from Sudan. She had a history of schizophrenia and suicidal thoughts, but the agency made no effort to procure information about her health and transferred her without medical notes to another facility, where she was put in isolation for long periods.

When contacted for comment, the department referred POLITICO to Border Patrol and ICE. Border Patrol said it conveys information about patients when it’s transferring them, albeit in paper form. ICE said it uses electronic records in its facilities, and says partner facilities agree to good documentation standards.

Rep. Lauren Underwood drew attention to the inadequate records during a visit to the Texas border this summer. At one facility, the Ursula Border Patrol detention center, Underwood said, agents were conducting visual assessment of migrants for signs of illness. “They are not keeping records/charts on each individual,” she wrote in a memo filed with the House Oversight Committee, which was investigating children separated from their families .

Underwood subsequently introduced the U.S. Border Patrol Medical Screening Standards Act, H.R. 3525 (116), which passed in the House in September. But adoption of a digital record by Border Patrol, which said it was already creating one, addresses only some of the problems.

“What we see globally throughout the system are failures to keep comprehensive medical records that are consistent with professional norms,” said Jared Davidson, a lawyer with the Southern Poverty Law Center.

Adding to the difficulty, many non-governmental physicians who care for refugees and immigrants decline to enter their records into computers, out of concern the data will be used by authorities to refuse assistance or otherwise discriminate against them.

Tens of thousands of migrants move through detention centers each month, often handed off from the Border Patrol to ICE or, if they are children, to the Health and Human Services Department’s Office of Refugee Resettlement. Others are released to sponsors pending claims of asylum. When they’re sick, their caregivers rely on medical records that are partial, incomplete or unreadable, say health care providers and immigration activists.

In 2013, when detainee Raul Ernesto Morales-Ramos complained of persistent gastrointestinal pain, staff found blood in his stool and requested a referral through the ICE software, called ICE Health Services Corp Medical Payment Authorization Request.

But the software failed to automatically alert facility staff of the status of the referral request, leaving Morales-Ramos untreated in the meantime. He died of cancer in 2015, aged 44, following a “critical lapse of care,” according to the ICE review. The software used by ICE still doesn’t provide electronic notifications to users, the agency confirmed in a statement.

Physicians who work with the records say it’s almost impossible to glean clear understandings of the patient’s condition from them.

“I typically get a combination of scanned paper records and some printouts from electronic medical records,” said Parveen Parmar, a University of Southern California emergency medicine doctor who has reviewed the records of detainees, both dead and living, on behalf of immigration lawyers. “The records are challenging to read, generally completely disorganized, and records often reflect minimal/poor charting that doesn’t meet a community standard of care.”

Homeland Security has touted efforts to digitize its record keeping, announcing in 2014 that ICE was adopting an eClinicalWorks digital health record to replace previous “legacy systems and paper-based files.” But that’s just one set of records in the bureaucratic snarl where the health of detainees is documented — or fails to be.

ICE shares some facilities with state and local governments, and Border Patrol is responsible for patients to be picked up at the border. The agencies all have different policies, and their software doesn’t seem to consistently transmit information, according to advocates .

Immigrants experience Homeland Security’s substandard medical care, and its related record-keeping standards, while waiting in Mexico to present themselves at the border; in a Customs, ICE or ICE-partnered facility; in an HHS center or in private clinics as they await adjudication of their immigration cases.

Transitions are becoming more frequent with the recent surge of individuals detained at the border, said Cristobal Ramón, a policy analyst with the Bipartisan Policy Center.

Hannah Janeway, a University of California, Los Angeles emergency medicine doctor, treats patients in Tijuana before they present themselves to Homeland Security seeking asylum. Once they arrive, however, “There’s no warm handoff,” she said, and little human-to-human communication.

“You see people in the Tijuana side, they have hope,” said Julie Sierra, a University of California, San Diego doctor who treats patients on the Mexican side of the border before they seek asylum in the United States, and in San Diego, after they’re released from custody. “You see them on the U.S. side, they’re like, what … just happened to me?”

Asylum-seekers often exit Homeland Security custody into the care of a sponsor while they’re waiting for their case to get adjudicated. Doctors who care for patients at that stage say they frequently arrive without documentation.

Since December 2018, UC San Diego doctor Linda Hill’s group has screened roughly 15,000 patients arriving at a local shelter from DHS custody. “Sometimes we get information about what they were treated for when they were in custody … oftentimes we don’t,” she said. “That is less than ideal.”

“There may be a few things about health concerns scribbled” in records he gets on patients released from Homeland Security, says Richard Wahl, a pediatrician with the University of Arizona.

Janeway, Hill and Wahl stick to paper records when they care for the asylum-seekers. Medical information could be weaponized against immigrants, they say, for example through the administration’s “public charge” rule — which would deny migrants green cards if they use public insurance or welfare programs.

The lack of records hurts patients, who often can’t advocate for their own care. “It can take a month or longer to even get folks’ medical records,” Davidson said. “We see people getting the runaround.”

While HHS’ records are “complete and comprehensive,” Homeland Security is “a little bit of a black hole,” said Rebekah Fletcher, a Seattle-area lawyer with KIND, a group representing children appearing in immigration court.

“We don’t tend to see if a child received care, specialty care, at DHS,” she said. Records often include two-page screening forms completed by Border Patrol agents, she said, but the information is limited. Border Patrol says it shares appropriate discharge and care information when detainees are transferred.

ICE said in a release that its agency-staffed facilities have electronic health records, and that partner facilities are expected to live up to agency standards. However, Homeland Security’s Office of Inspector General has questioned whether ICE is effective at holding partner facilities accountable.

Homeland Security was also responsible for the bungled implementation of an Epic Systems in 2016 that left the Coast Guard reliant on paper records.