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The 2017 Healthcare Informatics Innovator Awards: Third-Place Winning Team—East Boston Neighborhood Health Center

January 23, 2017
by Rajiv Leventhal
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Connecting the body and mind with a next-level health IT-based behavioral health integration program

Isolated from metropolitan Boston by water and tunnel, East Boston Neighborhood Health Center (EBNHC) is no stranger to improving health access and outcomes for underserved populations in the greater Boston area. Indeed, for 45 years, the federally qualified health center (FQHC)—one of the largest of its kind in the U.S. with a yearly visit volume of 294,000 serving over 66,000 patients—has been caring for a mostly lower-income patient population, and has more recently grown up to meet the needs of a constantly changing diverse community, which currently consists of mostly Latino immigrants.

The health center is a primary care facility with various departments including: adult medicine, pediatrics, family medicine, OB/GYN, an entire specialties practice, a chronic disease management program, and a behavioral health integration (BHI) program. Needless to say, senior leaders at the organization recognized early on that it needed to become an early adopter in health IT; EBNHC has been live on its electronic health record (EHR) since 1998.

What’s more, since 1976, EBNHC has provided onsite mental health services without interruption to this culturally diverse, at-risk population challenged by many social determinants of health. But that has not been easy to accomplish; all across the nation, health centers have been changing how they offer mental health services, of which conditions are extremely common, leading to healthcare costs of $57 billion a year, on par with cancer, according to 2014 data from The Commonwealth Fund.

Traditionally, patients have had to get a referral from a primary care provider to then see a mental health counselor in another department or location. But according to EBNHC officials, “That system doesn’t really make sense, because the body and the mind are connected. In order to be healthy, we need to treat the body and mind together.” This basic concept is supported by the Affordable Care Act (ACA) and the Massachusetts Chapter 224 health reform act, which both state the importance of including of behavioral health in primary care, the organization attests.

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In December 2015, EBNHC was awarded a three-year grant from the Blue Cross Blue Shield of Massachusetts Foundation to be applied towards improving the effectiveness of its behavioral health integration program. As Michael Mancusi, chief behavioral health officer and practicing behavioral health clinician at EBNHC says, many organizations have a “co-located” behavioral health model, meaning behavioral services are in the same building as primary care services but are not necessarily fully integrated in terms of behavioral health clinicians and medical providers being team members. EBNHC also leveraged the “open access” model in which a patient on a primary care visit who had a mental health need could possibly see a behavioral health physician on that day—if someone was available.

Mancusi says, “We wanted to improve access and outcomes for both behavioral health and primary care patients, knowing perfectly well the behavioral health need is incredible—both here and nationally—but the rate at which people do follow through with the care is not very impressive. We know from the data that exists, that when the medical provider is involved, the rates of follow-up go up enormously and therefore outcomes improve,” he says. Mancusi adds, astoundingly, “That’s one of the biggest innovations here; we have integrated behavioral health into primary care and have shared the same medical records since the beginning.”

Indeed, EBNHC’s BHI program transitioned from an open access/co-located model to a fully functioning BHI program in December 2014. Within the program, each primary care department has an integrated behavioral health consultant. “We didn’t want patients who were coming in for a primary care visit to wait a month to see behavioral health provider,” Mancusi says.

Officials say that a key strategic initiative is to scale to the appropriate level of behavioral health services such that EBNHC can appropriately meet the clinical demands and needs of its patient population. The health center started its work specifically for the grant in January 2016, choosing to focus on the expansion of behavioral health services for children and adolescent patients, ages 5 to 21.

Key leaders of East Boston Neighborhood Health Center who worked on the organization's BHI project

The core goal of this project, recognized with a third-place finish in Healthcare Informatics’ Innovator Awards program this year, is the identification, treatment, management and outcome measurement of children and adolescents with depression and anxiety. Early on, organizational leaders knew they needed a method to ensure depression screenings were completed on a regular basis, that patients received consistent follow-up care, and that the health center provided the appropriate level of behavioral health care at the point of service in primary care.

“We felt like we needed a way to be able to able to track the cohort of patients and also to be able to alert everyone on the care team that there were certain screenings to do for those patients,” says CIO Laura Rogers. “We needed a way of using the EHR to alert physicians if a warm handoff [which EBNHC refers to as a referral and a conversation about the patient between the referral doctor and the behavioral health doctor] was needed between primary care and behavioral health specialists. These were the two areas we needed to focus on,” Rogers says.

As such, tools were built in the EHR to alert the care team members to perform screenings at regular intervals. Tools to allow patients, along with providers, to document their goals for improving symptoms were also built. And workflows were created to allow for immediate outreach and to track outcomes and follow-up plans. But even then, it was not enough to just track and store this data. EBNHC needed a way to make the data actionable so it could ensure patients were not falling through the cracks. So IT leaders then built an interactive dashboard in the EHR that aggregates all of the data collected through workflows for review, administration and monitoring. This dashboard allows all members of the care team to view overdue screenings and then drill down for outreach.

The data that’s being captured, says Corey Hanson, director of clinical applications, includes: how many patients were being referred to a behavioral health clinician; out of all those referrals, how many led to a warm handoff; what percentage of patients referred that got the warm handoff had a depression assessment performed initially; and how many of those with the depression assessment have had a follow-up assessment within a certain time period. “With the dashboards and reporting, we can put reports in front of users proactively to tell them what patients are due for follow-up assessments,” says Hanson. “We capture all of this data from a department perspective, compare pediatrics to family medicine, and to the whole organization, and when it spreads to the adult population, eventually we’ll be able to compare all departments together,” he says.

Hanson says he quickly realized how much of a need there was for EHRs to be able to support a behavioral health program. Most EHRs are good at the clinical side of life, but have less functionality available for the behavioral health side, he notes. “As we started to put this together to see our numbers and what teams were asking for in terms of tools for support, it really became obvious that what we were doing would improve clinicians’ lives which we hoped would directly improve patients’ lives.”

Challenges Persist

While there increasingly are more models and approaches to integrating behavioral and primary health, such integration has been difficult to achieve enterprise-wide. Mancusi says that in a primary care environment, philosophically it makes great sense to integrate, but “changing hearts and minds, and making the shift culturally that is necessary, is no easy thing on either end.” He adds, “People are finding themselves as key team members despite being trained on one side or the other. In order to support that adoption, we have to provide good solid evidence of change, and this makes a big difference in peoples’ lives.”

To this end, Mancusi calls for the creation of models that can be replicated nationwide. He gives an example of behavioral health clinicians, including psychiatrists, being embedded into a primary care practice, and making everyone team members using the core practices developed. “We say the basic principle behind the warm handoff is that most of these kids have great relationships with the pediatrician. But the kids and their families are reluctant to come see the behavioral health clinician, so in the model we leverage that relationship that the pediatrician has with the child and the family. The behavioral health doctor is now being described in the warm handoff as a colleague or team member,” he says.  And what does that do? Mancusi says it better ensures the visit will take place and much better ensures a follow-up visit. “With our population, these kids and their families will come in during crisis, and of course life goes on after the visit, so they don’t come back. But because of this model and the alerts that are built into the system, we can follow up on the kids we are concerned about and track progress over time,” he says.

The model that EBNHC has developed wasn’t entirely from scratch, either. The health center worked very closely with Cherokee Health Systems in Knoxville, Tennessee, whose behavioral health integration model is considered a blueprint for others to replicate. As such, EBNHC sent 22 individuals from its organization to Knoxville to witness Cherokee’s integrated care model training. In that group there were clinical leaders, physicians, administrative leaders, and behavioral health clinicians, Mancusi recalls. “What’s fascinating about them is that they began as community mental health organization, and then added primary care. So on a national level they know a lot about [integration]—maybe the most of any organization in the U.S.,” Mancusi says. “That’s the model we have built ours around, and also other models that feature the warm handoff. But Cherokee is where we started from,” he says.

Nonetheless, Mancusi still notes that one of the biggest challenges for the health center was actually getting clinicians to see the value in the warm handoff. “Providers are naturally very busy, so to interrupt them when they are already behind is tough, but it’s necessary in order to really do this right. The behavioral health and medical providers have to meet together about the patient, and meet briefly with the patient together, to endorse the purpose and to talk about the symptoms. And then the behavioral clinician needs to meet with the patient, initiate care, and in the best of all possible worlds, goes back to the medical provider for a reverse handoff,” he explains. This “purist model” can be hard to pull off, Mancusi admits. “People have to be convinced of the value added,” he says.

Leslie Scherl, M.D., pediatrician at EBNHC, adds that when this model was introduced, there was pushback. “There is a sentiment here that if something is hard to do, we pretty much just tell the primary care providers to do it,” Scherl says. “But I do feel that those of us who can utilize these services now see how beneficial it is. Like everything else you have early resisters, early adopters, and people in the middle.” Scherl notes how the benefits are seen on the patient side as well, as they often lead chaotic lives so getting to see clinicians on both sides in the same day “can be amazing.”

A Worthy Endeavor

Six months into the project’s launch, the health center was able to increase its screening capture rate by 53 percent due to the alert and screening tools being available to the entire team. Also during the first six months, EBNHC was able to provide 233 warm handoff visits.

Chris Ascencio, behavioral health program manager, notes, “We have seen a much higher rate of completed appointments with this project as well, so [that means] the amount of patients served in behavioral health has increased dramatically in this program.” All of the project’s leaders especially touted its potential impact on the identification and treatment of behavioral health in adolescents and its likely positive impact on the rate at which patients return for critically needed follow-up visits after an initial warm handoff.

Indeed, EBNHC’s own internal data indicates a return rate of approximately 80 percent following a warm handoff whereas the return rate without one is approximately 30 percent. “It is not enough to build tracking tools and workflows; we need ways to ensure that these patients are not lost to care and with our dashboards we will be able to closely monitor future follow up and improvement based on interventions,” Rogers says, adding that the goal is to increase the number of patients seen for behavioral health within primary care by 10 percent in the first year as well as a reduction of 20 percent in PH9 scores (a depression test questionnaire) for follow-up screenings.

Mancusi references NIMH [National Institute of Mental Health] statistics which found that approximately 13 percent of children ages 8 to 15 had a diagnosable mental disorder this past year. “The data compellingly justifies the need to create programs such as ours embedded within the pediatrics team to together identify and treat this cohort in an effort to change lifetime outcomes,” he says.


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Gazing Into the Crystal Ball with LRVHealth’s Keith Figlioli

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2019 Predictions on Value-Based Care, Digital Startups, EHR Trends

Here’s a confession: I am much better at writing end-of-year review stories than I am at looking into the crystal ball for preview pieces at the beginning of the year. I might be able to make educated guesses about which issues we will be writing about in the coming year, but I prefer leave predictions about what is actually going to happen to others.

Luckily, people braver and more knowledgeable than I am are willing to weigh in. For instance, Dave Levin, M.D., chief medical officer of Sansoro Health recently shared his predictions for 2019 with Healthcare Informatics. One of his predictions is that “the excitement around new health IT players like Apple and Amazon will fade in late 2019. We need fresh ideas, but in the short-term, expect disappointments and missteps. Health IT (and healthcare in general) is much harder than it looks and the winners in the long-run will master the mash-up of the best of old and new. Health IT history is littered with companies like these that underestimate this challenge.” Good point!

Dave’s company, Sansoro Health, provides a set of APIs that read and write to EHRs. One of its investors is Boston-based LRVHealth, and one of LRVHealth’s general partners is Keith Figlioli, who served as senior vice president of healthcare informatics at Premier Inc. for nearly a decade. In December I spoke with Keith about some of his predictions for 2019.

One is that capital will be less abundant for digital health startups in 2019. I asked him why he thought that would be the case. “There already is a tremendous amount of capital in this space, including capital coming from other industries. The threat is that capital could be less abundant,” Figlioli said. “We are starting to see earlier stage companies have a little harder time raising capital. What that signals to us is that the greater market is pushing capital to later stages. Because capital can be harder to get in earlier rounds, valuations tend to float down a bit. The other thing is that the greater macro economy does feel like things are shifting a bit and that will also have an effect. I think 2019 may be a peaking year for valuations. I don’t think we are going to go much higher than we are right now.”

While Dave Levin had predicted that the enthusiasm about outside disruption from Big Tech might fade by the end of 2019, Figlioli predicted that these emerging entrants will start showing their cards. “Some of these guys are fairly secretive in their moves, but Apple has been hiring in healthcare and Amazon acquired PillPack. My sense is that we are going to know more about the ones that have been secretive,” he said. Now that the CVS/Aetna deal is done they will start to reveal more, he added. “We are going to see more announcements from these players over the course of 2019. People will be able to start deciphering what their plans are, at least out of the gate.” With its leadership in place, the Amazon/Berkshire Hathaway/JP Morgan entity will reveal an initiative, he predicted.

He also noted that Walgreens made some strategic announcements in 2018. “I call them the sleeping giant now, because CVS and Aetna made all the noise with their purchase deal. But Walgreens is making some very calculated moves with the incumbent players.”

Figlioli predicts that in 2019 the pace will pick up again on value-based care activity. “At LRVHealth, we have a saying that value-based care is inevitable but it is gradual,” he said. “I think we are finally going to get back up on the hamster wheel with things that really matter, because it feels like we have basically been at a dead stop since Trump took office.” He expects to see a handful of new mandatory and voluntary programs across cancer, cardiac and new bundled payment models. “When [HHS Secretary] Azar came in, it revved the engine back up and he is talking very publicly about ramping up mandatory programs. I think another signal is him talking more about CMMI [the Center for Medicare & Medicaid Innovation] and what may come out of it in terms of social determinants of health. I think we will see one or two CMMI pilots in 2019 dedicated to social determinants.”

In a related prediction, he said we should expect to see community programs such as local food banks become more closely affiliated with healthcare providers and payers. And just as there have been startups in the transportation area of social determinants, expect to see a few food-as-medicine related startups emerge in 2019, he added.

Figlioli’s final prediction touches on something I have written about a few times, the new “app store” approach to EHR add-ons. With open APIs gradually becoming the norm, he said, more CIOs who will become comfortable layering best-of-breed applications on top.

“There has been this lure in the CIO suite to say that the EHR vendor is going to do everything.  But because of what Cerner and Epic are doing and what athena has done all along, we are finally getting to a place where the average CIO is going to going to be OK going back to more of a hybrid model.” He stressed that the core EHR is not going anywhere. “You can think about them the same way you do about ERP systems. Over the last five years there has been a proliferation of overlays on top of them. And I feel like we are finally going to get to that with the EHR. It is not going to be clean or easy. There are going to be issues. It is going to be a pretty messy situation depending on how FHIR gets implemented. But it will become more of a cultural norm that Epic and Cerner don’t have to do everything. CIOs will say, ‘we are OK with them being our core workflow tool, but now we are allowing an overlay to take place.’”

 

 

 

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Research: Physician Burnout is a Public Health Crisis; Improving EHR Usability is Critical

January 18, 2019
by Heather Landi, Associate Editor
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Physician burnout is a public health crisis and addressing the problem requires improving electronic health record (EHR) standards with a strong focus on usability and open application programming interfaces (APIs), according to a new report from leading healthcare researchers.

The report is a “call to action,” the researchers wrote, “to begin to turn the tide before the consequences grow still more severe.” The researchers also recommend “systemic and institutional reforms” that are critical to mitigating the prevalence of burnout.

The result of collaboration between researchers with the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T. H. Chan School of Public Health, and the Harvard Global Health Institute, the report's aim is to inform and enable physicians and health care leaders to assess the magnitude of the challenge presented by physician burnout in their work and organizations, and to take appropriate measures to address the challenge, the researchers say.

The report also offers recommended actions for healthcare leaders to take, which the researchers acknowledge are not exhaustive, but “represent short-, medium-, and long-term interventions with the potential for significant impact as standalone interventions.”

The authors of the report include Ashish K. Jha, M.D., the K.T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health, and director of the Harvard Global Health Institute; Andrew Iliff, lead writer and program manager, Harvard Global Health Institute; Alain Chaoui, M.D., president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration, Massachusetts Health and Hospital Association; Maryanne Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael Miller, director, practice solutions and medical economics, Massachusetts Medical Society.

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession, according to the report.

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000-$1,000.000. 

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” Dr. Jha, a VA physician and Harvard faculty member, said in a statement in a press release accompanying the report. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

The beginning of the physician burnout crisis can be traced back to several events, according to the researchers, including the “meaningful use” of electronic health records, “which transformed the practice of many physicians, and was mandated as part of the 2009 American Reinvestment and Recovery Act.” Going back further, the 1999 publication of the Institute of Medicine’s “To Err is Human” highlighted the prevalence of medical errors, brought new attention to quality improvement and the value of physician reporting and accountability, the report states.

The researchers note that the primary impact of burnout is on physicians’ mental health, “but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public,” the researchers wrote.

The researchers note, “If we do not immediately take effective steps to reduce burnout, not only will physicians’ work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe.”

And, while individual physicians can take steps to better cope with work stress and hold at bay the symptoms of burnout, “meaningful steps to address the crisis and its root causes must be taken at a systemic and institutional level,” the researchers wrote.

According to the researchers, the primary drivers of physician burnout are structural features of current medical practice. “Only structural solutions — those that better align the work of physicians with their mission — will have significant and durable impact,” the researchers wrote in the report.

To that end, the researchers’ immediate recommendation is for healthcare institutions to improve access to and expand health services for physicians, including mental health services.

In the medium term, technology can play a large role. Addressing physician burnout will require “significant” changes to the usability of EHRs, the researchers wrote, including reform of certification standards by the federal government; improved interoperability; the use of application programming interfaces (APIs) by vendors; dramatically increased physician engagement in the design, implementation and customization of EHRs; and an ongoing commitment to reducing the burden of documentation and measurement placed on physicians by payers and health care organizations.

New EHR standards from the Office of the National Coordinator for Health IT (ONC) that address the usability and workflow concerns of physicians are long overdue, the researchers state. One promising solution would be to permit software developers to develop a range of apps that can operate with most, if not all, certified EHR systems, according to the report. The 21st Century Cures Act of 2016 mandates the use of open APIs, which standardize programming interactions, allowing third parties to develop apps that can work with any EHR with “no special effort.” There already have been efforts on this front, such as Epic’s “App Orchard,” the researchers note, but more work remains to be done.

To expedite this critical process of improvement, the report recommends physicians, practices, and larger health care delivery organizations, when seeking to purchase or renew contracts for health IT, adopt common RFP language specifying and requiring inclusion of a uniform health care API.

The researchers also say that artificial intelligence (AI) can play a promising role as AI technologies can support clinical documentation and quality measurement activities.

Long term, healthcare institutions need to appoint executive-level chief wellness officers who will be tasked with studying and assessing physician burnout. Chief wellness officers also can consult physicians to design, implement and continually improve interventions to reduce burnout, the researchers wrote.

“The fundamental challenge issued in this report is to health care institutions of all sizes to take action on physician burnout. The three recommendations advanced here should all be implemented as a matter of urgency and will yield benefits in the short, medium, and long term,” Jha and the research team wrote.

 

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GAO Report: Patient Matching Efforts Can Be Significantly Improved

January 17, 2019
by Rajiv Leventhal, Managing Editor
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The report did conclude that no single effort would solve the challenge of patient record matching

There is a lot that can be done—such as implementing common standards for recording demographic data—to improve patient matching, according to a new Government Accountability Office (GAO) report that closely examined the issue.

The 21st Century Cures Act included a provision for GAO to study patient record matching, and in this report, GAO describes (1) stakeholders' patient record matching approaches and related challenges; and (2) efforts to improve patient record matching identified by stakeholders.

The 37 stakeholders that GAO interviewed, including representatives from physician practices and hospitals, described their approaches for matching patients' records—comparing patient information in different health records to determine if the records refer to the same patient.

The respondents explained that when exchanging health information with other providers, they match patients' medical records using demographic information, such as the patient's name, date of birth, or sex. This record matching can be done manually or automatically. For example, several provider representatives said that they rely on software that automatically matches records based on the records' demographic information when receiving medical records electronically.

Stakeholders further said that software can also identify potential matches, which staff then manually review to determine whether the records correspond to the same patient. They said that inaccurate, incomplete, or inconsistently formatted demographic information in patients' records can pose challenges to accurate matching. For example, records don't always contain correct information (e.g., a patient may provide a nickname rather than a legal name) and that health IT systems and providers use different formats for key information such as names that contain hyphens.

Those who GAO interviewed identified recent or ongoing efforts to improve the data and methods used in patient record matching, such as the following:

  • ·         Several stakeholders told GAO they worked to improve the consistency with which they format demographic data in their electronic health records (EHR). In 2017, 23 providers in Texas implemented standards for how staff record patients' names, addresses, and other data. Representatives from three hospitals said this increased their ability to match patients' medical records automatically. For example, one hospital's representatives said they had seen a significant decrease in the need to manually review records that do not match automatically.
  • ·         Stakeholders also described efforts to assess and improve the effectiveness of methods used to match patient records. For example, in 2017 the Office of the National Coordinator for Health Information Technology (ONC) hosted a competition for participants to create an algorithm that most accurately matched patient records. ONC selected six winning submissions and plans to report on their analysis of the competition's data.

Those who were interviewed said more could be done to improve patient record matching, and identified several efforts that could improve matching. For example, some said that implementing common standards for recording demographic data; sharing best practices and other resources; and developing a public-private collaboration effort could each improve matching.

Stakeholders' views varied on the roles ONC and others should play in these efforts and the extent to which the efforts would improve matching. For example, some said that ONC could require demographic data standards as part of its responsibility for certifying EHR systems, while other stakeholders said that ONC could facilitate the voluntary adoption of such standards. Multiple stakeholders emphasized that no single effort would solve the challenge of patient record matching.

To this end, a recent report from the Pew Charitable Trusts outlined several key themes related to patient matching, while also suggesting recommendations to improve matching and the infrastructure needed for more robust progress in the medium and long term.

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