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Geisinger’s Data-Driven Approach to Reducing Prescription Opioid Abuse

April 27, 2018
by Heather Landi
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Opioid addiction and opioid-related deaths have increased dramatically in the United States in the past decade and healthcare provider organizations across the country are grappling with finding ways to curb the nation’s opioid epidemic.

According to the Centers for Disease Control and Prevention (CDC), deaths from drug overdoses in the U.S. totaled more than 63,600 in 2016, with 42,249 of those deaths attributed to opioids. The death rate from opioid overdoses was five times higher in 2016 than in 1999. In a state-by-state analysis, in 2016 West Virginia had the highest death rate per 100,000 population, followed by Ohio, New Hampshire and Pennsylvania.

During a webinar April 25 sponsored by the College of Healthcare Information Management Executives (CHIME) Opioid Task Force, executive leaders at the Danville, Pa.-based Geisinger Health System outlined a multifaceted, data-driven initiative by health system leaders to address the opioid crisis in Pennsylvania.

“Opioids have been a challenge for us,” acknowledged John Kravitz, CIO at Geisinger Health System, citing the statistic that Pennsylvania’s opioid overdose death rate was the fourth highest in the country. In 2016, there were 4,642 drug-related drug deaths in the state, with 85 percent involving opioids and one in four being prescription opioids. What’s more, many of the counties with the highest death rates in 2016 were served by Geisinger Health System.

Kravitz, along with Richard Taylor, M.D., Geisinger’s chief medical information officer (CMIO) and Michael Evans, Geisinger’s vice president of enterprise pharmacy and chief pharmacy officer, detailed the health system’s effort to utilize data and health IT tools to change providers’ prescribing practices. As a result of this effort, the health system has slashed opioid prescriptions in half, from a monthly average of 60,000 opioid prescriptions to 31,000 prescriptions per month.

Geisinger Health System consists of 12 hospitals and 700 clinics with 2,400 employed physicians and more than 4,000 affiliated physicians. The health system’s reach includes more than 3 million residents in 45 counties in central, south-central and northeast Pennsylvania and southern New Jersey. As an integrated system, Geisinger also operates a health plan with 600,000 members.

According to Kravitz, physician leadership recognized the opioid crisis in its own communities and wanted to reverse the trends. By limiting or eliminating the prescribing of opioids in a clinical setting, physician leadership proposed, Geisinger could minimize or prevent a patient’s exposure to the drugs and the consequent risk of the patient developing an addiction that might lead to an overdose and death.

Physician leaders also recognized that reducing opioid addictions could ease the burden on the health system. An analysis of 942 patients in the Geisinger system who overdosed on opioids found a steep increase in the use of acute care, and especially emergency department services, prior to an overdose, according to Kravitz.

He emphasized that addressing prescription opioid abuse requires a multifaceted, holistic effort that includes encouraging effective non-opioid therapies for pain management. “Technology is not the silver bullet to solving this problem; there is no single silver bullet,” he said.

Kravitz noted that the original intent of the initiative wasn’t to reduce opioid prescriptions, but to ensure appropriate pain management with the recognition than non-opioid therapies would help patients avoid the side effects of opioids and reduce the potential risk of addiction. In the surgical setting, Geisinger leaders designed a pain management program in which patients and their families were counseled to expect some manageable pain after relatively minor procedures. At discharge, providers were encouraged to offer nonaddictive alternatives to opioids for managing pain, such as Tylenol, nonsteroidal anti-inflammatory drugs or other novel medications. If a physician decided an opioid prescription was in the best interest of a patient, the physician was encouraged to use the smallest effective dosage prescribed for three days or less, Kravitz said.

In addition, for chronic pain patients and patients at risk of addiction, Geisinger recommended therapies such as rehabilitation, exercise, cognitive behavioral therapies, yoga and acupuncture rather than opioids. Taylor noted that a Geisinger study found that opioids are not helpful in treating chronic pain, and that side effects of chronic opioid therapy include risk of addiction and depression and other potential health problems.

Geisinger project leaders developed and initiated several approaches that focused on changing physician practice patterns to reduce the prescribing of opioids. Data and IT were foundational to these efforts, as physician leadership developed a provider dashboard linked to the electronic health record (EHR) to identify current practice patterns among Geisinger providers. With this baseline data, Geisinger physician leaders found that providers varied greatly in their opioid prescribing patterns, with a relatively small number being heavy prescribers. They then used that information to first target the outliers and provide them with best practices for pain management.

“Having the dashboard linked into EHR has been critical to success,” Kravitz said. “When we meet with physician provider groups, the typical response is, ‘I had no idea that I was prescribing that much controlled substance, that much opioid.’ It has helped prescribers as they are managing their own patient populations. It shows the fill data around what the patients are doing and the data will tell you if there are patients going to three different providers for three different medications and filled at three different pharmacies.”

The state’s prescription drug monitoring database (PDMP) is another tool providers can use to identify diversions, Kravitz noted, and Geisinger’s IT leaders worked to leverage the state’s PDMP. In Pennsylvania, all prescribers and dispensers (pharmacies) are required to register with the PDMP. Prescribers must query the system each time a patient is prescribed an opioid drug product and dispensers are required to submit data to the PDMP after dispensing a controlled substance.

“We are working with state to get APIs (application programming interfaces) to connect to providers’ workflow, so that it’s in the background. I think we’ll see the delivery of those APIs in the next three months or so. It’s an important step that has to occur, checking the PDMP to see if a patient is a ‘frequent flyer,’ so to speak, and we are working to make that automatic,” Evans said.

Geisinger leaders created tools to track documentation within the EHR and dashboard that indicates that providers reviewed the state-run PDMP, as mandated by the state, and if they considered prescribing a controlled substance. In addition, Geisinger leaders developed a pain app that measures physical activity, patient-reported pain and other metrics and that information is integrated into the provider dashboard and the patient’s medical record as well.

As part of this initiative, Geisinger IT and pharmacy leaders also enabled electronic prescribing for controlled substances (EPCS), noting that written prescriptions pose many challenges, including errors and inaccuracies and the potential for forgeries.

“We set out to identity-proof and authenticate the provider population and we went live last year with EPCS, using a smartphone authentication. We enrolled 1,300 providers on the first day and continue to enroll dozens per month,” Evans said. Currently, 74 percent of controlled medications are being ePrescribed, with 82 percent outpatient adoption and 20 percent inpatient adoption. What’s more, 126 clinics are at 100 percent ePrescribing of controlled substances, Evans said, and 1,662 of Geisinger employed physicians, or 62 percent, are identity-proofed to use the EPCS system.

“We have a vision of no written prescriptions at Geisinger, and we expect to cross that milestone in months, not years. We are targeting every Geisinger provider and we think we can get very close before we have to drop the hammer with a mandate,” he said.

As mentioned above, the initiative has resulted in an almost 50 percent reduction in the number of opioid prescriptions per month, on average. What’s more, Geisinger leaders also reported that the use of e-prescribing for controlled substances created $1 million in savings within five months due to greater efficiencies.

“As I said, there is no silver bullet, but using provider dashboards and with EPCS, we can focus on intervening and we can use the dashboards to help us understand where people are in trouble,” Kravitz said.

He also noted that while the provider dashboard is unique to Geisinger, the underlying processes and strategy involved with this initiative can be replicated by other health systems and hospitals. “We love analytics, and we have two big data platforms, not just one, that we really enjoy utilizing. But, you don’t have to have analytics or big data platforms to identify the prescribing habits of providers,” he said, noting that health systems and hospitals can generate reports on opioid prescribing through their EHRs or clinical order entry systems. “It’s something we can all take part in and dig in and look at practice patterns,” he said.

Taylor adds that, to succeed, organizations will need support from their physician leadership and a commitment to eliminating all unnecessary opioid prescribing. “Information technology is a powerful tool, but its effectiveness is limited without buy-in from clinicians and administrators,” Kravitz said.


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ASCO Picks IBM Watson Exec to Lead CancerLinQ

August 10, 2018
by David Raths
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Big data platform collects and analyzes data from cancer patients at practices nationwide

The American Society of Clinical Oncology (ASCO) has named a former IBM Watson executive as the new CEO of its CancerLinQ big data platform.

Cory Wiegert was most recently vice president of product management for IBM Watson Health. Prior to joining IBM, Wiegert held positions with Sterling Commerce, Siebel Systems Inc., Centura Software and Safety-Kleen.

Kevin Fitzpatrick stepped down as the nonprofit CancerLinQ’s CEO in April 2018. Richard Schilsky, M.D., who was serving as interim CEO of CancerLinQ, will continue his role as ASCO's chief medical officer.

CancerLinQ collects and analyzes data from cancer patients at practices nationwide, drawing from electronic health records, to inform and improve the quality of cancer care. Its database contains more than a million cancer patient records. The effort has two major components:

• The CancerLinQ quality improvement and data-sharing platform for oncology practices,

• CancerLinQ Discovery, which provides access to high-quality, de-identified datasets derived from the patient data to academic researchers, non-profit organizations, government agencies, industry, and others in the oncology community.

CancerLinQ LLC also has established a number of collaborations with government and nonprofit entities -- including American Society of Radiation Oncology, Food and Drug Administration, and the National Cancer Institute -- as well as industry through its collaborators AstraZeneca, Tempus, and Concerto HealthAI.

In a statement, ASCO CEO and CancerLinQ LLC Board of Governors Chair Clifford A. Hudis, M.D., said Wiegert’s arrival “comes at a pivotal time, as we are quickly building on and improving CancerLinQ's core quality improvement platform for oncologists and data analytics services for the broader cancer community."

As CEO, Wiegert will be tasked with developing new solutions to help oncology practices improve the day-to-day care they provide their patients and continuing to serve CancerLinQ collaborators.




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A ‘Google’ for Clinical Notes Draws Interest

August 8, 2018
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Developed at the University of Michigan, EMERSE allows users to search the EHR’s unstructured clinical notes
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Those of us who cover healthcare informatics often hear clinicians and researchers talk about the problems involved in doing analytics or research on unstructured data in clinical notes. That was why I was intrigued when I saw that informatics teams at the University of North Carolina School of Medicine are implementing a tool called EMERSE (Electronic Medical Record Search Engine), which allows users to search free-text clinical notes from the electronic health record (EHR). They describe it as being like "Google" for clinical notes. 

But then I noticed that the tool was actually created quite a while ago, in 2005, at the University of Michigan, and has been in use there ever since. So I reached out to its developer, David Hanauer, M.D., a clinical associate professor of pediatrics and communicable diseases at the University of Michigan Medical School. He also serves as assistant director for clinical informatics in UM’s Comprehensive Cancer Center’s Informatics Core as well as associate chief medical information officer at the UM Medical Center.

Hanauer told me that the developers of EMERSE at Michigan have a grant from the National Cancer Institute to further develop the tool and help disseminate it, with a focus on cancer centers around the country. “We are about one year into the grant,” he said. “We have spent the last year cleaning up the infrastructure to make it even easier for people to adopt. We have been working hard on technical documentation. When we started it, we had almost no documentation; now we have substantial and detailed documentation about how to implement and run it.”  

The five sites implementing EMERSE as part of the grant are the University of North Carolina, University of Kentucky, University of Cincinnati, Case Western Reserve University and Columbia University.

I asked Hanauer if health systems continue to struggle with unstructured data in clinical notes. “They all absolutely struggle with it,” he said. “They have mostly been ignoring it, to tell you the truth. That is why we believe and hope EMERSE will fit well into this environment of people needing different tools.”

I also asked him to describe some of the use cases. Most generically, anybody who needs to look through the chart and doesn’t know exactly where to look can get benefit from it, he said. He described three categories of users: research, clinical care and operations. “For example, in research you could use it for cohort identification. You want to find patients who meet your needs when it comes to a research study. This is important in part because ICD codes, the go-to way people often try to identify a cohort, are often inaccurate and non-specific.”

According to the EMERSE web site, for studies in which eligibility determination is complex and may rely on data only captured within the free text portion of documents, EMERSE can be a rapid way to check for mentions of inclusion/exclusion criteria.

In another example, EMERSE also can be used to help find details about a patient rapidly, even during a clinical visit. “For example, if a patient mentions that a certain medication helped their migraine three years ago but can’t remember the name, just search the chart for 'migraine' and find that note within seconds,” the web site notes. Cancer registrars can use EMERSE for data abstraction tasks, including difficult-to-find information such as genetic and biomarker testing.

Hanauer said at Michigan, clinicians have a way to access EMERSE from their Epic EHR. “If you have a patient’s record open, you can click a button, it will log you into EMERSE and bring that patient’s context over, and you can start searching in just of a few seconds.”

In 2005, the platform was written to work with a homegrown EHR. When UM transitioned to Epic in 2012, Hanauer and team used that as an opportunity to make it more powerful. “When we went live with Epic, it became clear there were some architectural limitations that were probably going to limit the future power of the software,” he recalled. “We leveraged the design and concepts and rewrote it from scratch. But even though we were going to work with Epic, we designed it specifically so it would not be tied to any particular EHR.”

Because it deals with patient records, security and audit logs have to be taken very seriously. Every time you log into EMERSE, you come to an attestation page. “You have to declare why you are using it for this session,” Hanauer explained. “We have tried to make it as simple as possible. Almost every institution that does research now has an electronic IRB system, so we have a way you can pull a user’s IRB-approved study into the EMERSE database, and a list appears of that user’s studies only. The user can click on it, record that use, and move forward.” There also are quick buttons for common administrative use cases.

I asked Hanauer if other academic medical centers had developed similar search tools. He said some have created local tools. “The main difference with EMERSE is that it is proven it can work elsewhere. (It was used at the VA in Ann Arbor, Mich., on the VistA system.) “We have a long track record of use and have been working on the infrastructure to disseminate it,” he said. “We are giving it away at no cost, but it is almost like running a software company, where you have to have a web site, user documentation, and system administrator documentation. To me, it doesn’t make a lot of sense for others to reinvent the wheel when this is something we have invested millions of dollars in at this point.”

He stressed that although the grant project is focused on five cancer centers, they are giving the software away at no cost, and are glad to help anybody interested in getting it up and running. “One of the key challenges is that the users can’t control whether it gets deployed or not,” he said. “Our biggest challenges is not the users, who are contacting us and asking us for it, but getting this through local IT leadership, and that is a big hurdle.”

Why would CIOs be opposed to deploying this tool? “I think their plates are full and a lot of times people are looking for vendor solutions,” he surmised.  “I also think that often people don’t understand what the issues are. Some people think they will just get some off-the-shelf NLP software. But I can assure you that that software will not be able to do the kinds of things that EMERSE can do. That is partly because a lot of medical documents are not in natural language. Medical documents are anything but. They are a mess.”



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Anthem Expands $500M Deal with IBM with Focus on IT Automation, AI

July 26, 2018
by Heather Landi
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Health insurer Anthem has expanded its services agreement with technology leader IBM with a focus on using artificial intelligence (AI) and automation to improve operational efficiency and modernize technology platforms.

With this collaboration, Armonk, New York-based IBM and Indianapolis-based Anthem, one of the largest U.S. health insurance coampnies, will work together to help drive Anthem’s digital transformation and deliver an enhanced digital experience for its nearly 40 million consumers, Anthem said in a press release.

In 2015, Anthem entered into a five-year, $500-million-dollar strategic technology services partnership with IBM in which the technology giant provided operational services for Anthem’s mainframe and data center server and storage infrastructure. As part of that agreement, Anthem has been able to leverage IBM Cloud solutions to increase the ease, availability and speed of adding infrastructure to support new business requirements, the company said.

Under the expanded agreement, IBM will provide Anthem with enterprise services for its mainframe and data center server and storage infrastructure management. In addition, IBM will work with Anthem towards creating an AI environment which will allow for an automated infrastructure providing 24/7 digital capabilities. This will bring greater value and access to Anthem's consumers, care providers, and employees, Anthem said.

IBM and Anthem will also continue to work together on IT automation. Since 2015, the two companies’ have implemented over 130 bots, automating over 70 percent of the monthly high volume repetitive tasks. This includes bots that can identify when a server is reaching capacity to shift workloads to other less utilized servers ensuring that work is not impacted. This capability has improved systems availability as well as freed up resources to work on higher-value projects, Anthem said in a press release.
“We are seeing a dynamic change in the healthcare industry, requiring us to be more agile and responsive, utilizing advanced technology like AI to drive better quality and outcomes for consumers,” Tim Skeen, senior vice president and chief information officer, Anthem, Inc., said in a statement. “Our continued strategic partnership with IBM will help establish a stronger foundation for Anthem to respond to the changing demands in the market, deliver greater quality of services for consumers and help accelerate Anthem’s focus on leading the transformation of healthcare to create a more accessible, more affordable, more accountable healthcare system for all Americans.”

“The collaboration between IBM Services and Anthem has already laid the groundwork to improve healthcare processes and quality,” said Martin Jetter, senior vice president, IBM Global Technology Services. “Our latest agreement will accelerate Anthem’s growth strategy and continued leadership as one of the largest healthcare insurance companies and provide a solid path to bringing new efficiencies in driving digital transformation.”


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