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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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How BI Tools Are Helping Jefferson Health Battle the Opioid Crisis

September 21, 2018
by David Raths, Contributing Editor
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Helping clinical leaders identify prescribing patterns across the health system

Making health system changes to address the opioid crisis is challenging if you don’t have actionable data about prescribing patterns. With guidance from their chief medical officer, the business intelligence team at Jefferson Health in Philadelphia took advantage of the recent enterprise EHR implementation to create dashboards highlighting potential prescribing issues. Internal EHR development teams have already made changes to address the issues they found.

In a recent interview, Cara Martino, enterprise business intelligence manager at 14-hospital Jefferson Health, said that Jefferson was one of the first health systems to implement its Epic EHR and Qlik Sense at the same time. Many organizations that go live on Epic use Crystal Reporting, she said. “It was the combination of the two that allowed us to do this project,” she added. Before going live on Epic and using this new BI tool, Jefferson clinicians used a bunch of disparate systems for ambulatory, inpatient and emergency department physicians. “We weren’t able to aggregate the data,” she recalled.

Jefferson departments had tried to look at opioid prescribing previously, but “they were trying to manually abstract opioid data from the system, compile it in Excel, and try to see trending across the continuum of care, but they really weren’t able to do that very well,” Martino said. “Once we went live with Epic, we were able to standardize the work flow of entering the opioid order and prescription, and Qlik Sense allowed us to look at it from that enterprise view and to slice and dice the data a bunch of different ways.”

In response to the opioid epidemic in the Philadelphia area, Jefferson has created an opioid task force. In January 2018, Edmund Pribitkin, M.D., Jefferson’s chief medical officer, came to the BI team because he saw they didn’t really have good data to share. “We were bringing physicians and pharmacists together in a room to think through what we can change to address the opioid crisis,” Martino said, “but they didn't’ have baseline data to understand where we are going wrong.”

Pribitkin asked the BI team to develop a high-level dashboard with five key metrics to share at the clinical chair department level: 

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• Prescriptions by provider and service;

• Number of orders with over 100 pills;

• Prescriptions written for more than 7 days, 5 days and 3 days;

• Patients with two or more opioid prescriptions within 30 days; and

• Morphine-equivalent daily doses over 50.

The metric around patients with two or more prescriptions within 30 days had been difficult to see when data was being entered in a lot of different ordering systems, but is much easier now because everyone is ordering through Epic.

Within a month, the BI team had a prototype created. In the dashboard, you can pick a patient with the most scripts, and below it populates the different providers who are prescribing for them. “Sometimes you pick someone on the higher end and only one person is prescribing to them. Usually it is a chronic pain clinician, and it is probably appropriate,” Martino said. “But then you pick someone who has six different providers providing them opiates. They may have no idea about each other. Now we get to have that conversation about what we can do in the EHR to notify them at the time of ordering that the patient already has something prescribed. Also, our quality department can notify these six providers via e-mail. They might ask whether we should refer this patient to a chronic pain physician. If they really need this much pain medication, are we treating them the right way?”

Showing clinical leaders a trending graph such as prescription orders of 7 days or more can have an impact on ordering trends and EHR recommendations. Martino, who is a nurse herself, described an example of how her team worked with clinician informaticists who build EHR workflow tools to make some key changes.

They saw in the data that there were examples of doctors were prescribing six opioids to the same patient within two minutes. On further examination, they found that clinicians were entering orders incorrectly and quickly canceling them. But the e-prescription interface with the pharmacy system wasn’t necessarily canceling the incorrect orders, and the patients could have six prescriptions waiting for them at the pharmacy.

“Our first step was to get a message out to providers to let them know if you are prescribing and sending to an outside pharmacy, you need to pick up the phone and talk to the pharmacy about a change in an order and make sure they know which is the correct one,” Martino said. They also worked on the pharmacy interface to generate those canceled order messages, so that if something is ordered and then canceled within 30 seconds, it alerts the pharmacy not to prepare it.

The BI team saw another EHR change that they thought might make a big difference in prescribing patterns. In the EHR quick buttons, duration of the prescription defaulted to 10 days. The quick button on order days had choices of 7, 10, 15 or 30. “We knew those were too high,” she said. “We wanted 3, 5 or 7.”

They worked with an emergency department doctor who was also an informaticist to pilot that change in the ED. “In the first month, we saw a drop from 32 scripts over 7 days to just two,” Martino said. The following month they saw a reduction of more than 65 percent in prescriptions of more than 7 days. “The best part is no one complained or said they were looking for the 10 button and it wasn’t there,” she added. Now that change is being rolled out enterprise-wide.

Although there are some other requests from clinicians for data about opioid prescribing, Martino said the BI team’s current goal is to help more clinicians gain insights into the data that already exists. “It is really hard to go from an institution that was not data-rich and had disparate systems and manually collected data to one that has one EHR and a robust BI tool that allows us to slice data in a million different ways,” Martino said. “We are trying to get the clinicians comfortable with the tools. There is so much we can do, but we have to get the data to the right people and educate them about how we are pulling it out of the EHR. It is easy for this not be a priority for clinicians because they are so invested in taking care of their patients. It is our job as informaticists to go to their meetings and talk about changes we can make. It is also important for us to have clinicians on our team and to be able to offer that informaticist viewpoint.”

 

 


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Survey: Physicians Sour on Value-Based Care Metrics, EHRs

September 19, 2018
by Rajiv Leventhal, Managing Editor
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They new research has several key findings related to value-based care, health IT and burnout

More than 50 percent of U.S. physicians who receive value-based care compensation said they do not believe that the metrics the reimbursement is tied to improve the quality of care or reduce costs, according to a new survey.

The research comes from The Physicians Foundation, an organization seeking to advance the work of practicing physicians and helps them facilitate the delivery of healthcare to patients. The Foundation’s 2018 survey of U.S. physicians, administered by Merritt Hawkins and inclusive of responses from almost 9,000 physicians across the country, reveals the impact of several factors driving physicians to reassess their careers.

Specifically, the new survey underscores the overall impact of excessive regulatory/insurer requirements, loss of clinical autonomy and challenges with electronic health record (EHR) design/interoperability on physician attitudes toward their medical practice environment and overall dissatisfaction—all of which have led to professional burnout.

The research revealed several key findings, including that value-based compensation is directly connected to the overall dissatisfaction problem, which is tied to metrics such as EHR use, cost controls and readmission rates, etc. Forty-seven percent (compared to 43 percent in the 2016 survey) of physicians have their compensation tied to quality/value, but when physicians were asked if they believe that value-based payments are likely to improve quality of care and reduce costs, 57 percent either disagreed or strongly disagreed that this is the case, while only 18 percent either agreed or strongly agreed that it is.

As one responding physician put it: “We are no longer in the business of healthcare delivery, we are in the business of ‘measures’ delivery.” More than 13 percent of physicians are not sure if they are paid on value.

What’s more, the research found that 88 percent of physicians have reported that some, many or all of their patients are affected by social determinants. Conditions such as poverty, unemployment, lack of education, and addictions all pose a serious impediment to their health, well-being and eventual health outcomes. Only one percent of physicians reported that none of their patients had such conditions.

Additional notable findings from the research included:

  • 18.5 percent of physicians now practice some form of telemedicine
  • 80 percent of physicians report being at full capacity or being overextended
  • 40 percent of physicians plan to either retire in the next one to three years or cut back on hours—up from 36 percent in 2016
  • 32 percent of physicians do not see Medicaid patients or limit the number they see, while 22 percent of physicians do not see Medicare patients or limit the number they see
  • 46 percent of physicians indicate relations between physicians and hospitals are somewhat or mostly negative

Coupled altogether, 78 percent of physicians said they have experienced burnout in their medical practices, according to the survey’s findings. And the results show that one of the chief culprits contributing to physician burnout is indeed the frustration physicians feel with the inefficiency of EHRs.

“The perceptions of thousands of physicians in The Physicians Foundation’s latest survey reflect front-line observations of our healthcare system and its impact on all of us, and it’s sobering,” Gary Price, M.D., president of the Foundation, said in a statement. “Their responses provide important insights into many critical issues. The career plans and practice pattern trends revealed in this survey—some of which are a result of burnoutwill likely have a significant effect on our physician workforce, and ultimately, everyone’s access to care.”

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Brigham Health’s 3-Pronged Approach to Reducing EHR’s Contribution to Burnout

September 18, 2018
by David Raths, Contributing Editor
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Focus is on individualized training, reducing unnecessary clicks, voice recognition tools

Research studies have found that “burnout” is nearly twice as prevalent among physicians as among people in other professions.  Physician surveys have found that 30 to 60 percent report symptoms of burnout, which can threaten patient safety and physician health. With EHR documentation ranked high among aspects of their work physicians are dissatisfied with, Brigham Health in Boston has taken a three-pronged approach to reducing the pain.

Brigham Health, which is the parent organization that includes Brigham and Women’s Hospital, Brigham and Women’s Faulkner Hospital and the Brigham and Women’s Physicians Organization, rolled out its implementation of Epic in 2015. In a Sept. 18 presentation that was part of the Harvard Clinical Informatics Lecture Series, Brigham Chief Information Officer Adam Landman, M.D., said the organization’s initial EHR physician training was eight hours of classroom training on where to find things in the EHR instead of focusing on workflows and how to use the EHR to support it.  “Our experience was not the best,” Landman admitted.  They followed up with tip sheets, a help desk and a swat team to do service calls, but providers only rated those interventions as somewhat helpful, so Brigham informaticists re-doubled their efforts to:

• Improve the EHR;

• Provide one-on-one training in the clinical setting; and

• Offer voice recognition software and training.

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Landman said IT teams at Brigham feel a sense of urgency about reducing the burden of EHR documentation. “Burnout is an epidemic, and the EHR is a component of this,” he said, adding that the changes are not just a one-year cycle but must involve continual iterative improvements. “We need to be more aggressive about making changes,” he said.

He described some efforts to reduce notifications and remove clicks from the medication refill process. They also removed a hard stop when discontinuing a medication. Those three changes alone reduced the number of clicks per month by 950,000 across the health system.

They also worked to reduce clinical decision support alerts with very low acceptance rates by turning them off. Three alerts with very low acceptance rates were turned off. “If we thought they were important, we would fine tune them to increase the acceptance rate,” Landman stressed. “That is part of clinical decision support lifecycle management. But we will continue to iterate to reduce the number of unnecessary clicks.”

A year and a half ago, Brigham also created a one-to-one support program, in which an expert trainer would meet the physicians in their practice and help them with their work flow. A pilot project involved four specialties, including general surgery. Each session was 90 minutes to two hours long, and providers were offered one or more follow-up sessions, as well as optional training on speech recognition. After seeing some negative feedback on their initial classroom training, the one-to-one sessions were met with a very positive response. Almost 95 percent said it was valuable, and 95 percent said they thought their efficiency with the EHR would improve following the training. Based on that early success, the training effort is now being rolled out to much larger groups of physicians at Brigham and across the Partners HealthCare network.

In another attempt to improve documentation turnaround time, Brigham has made voice recognition tools and training available to physicians. They made two-hour training sessions mandatory for those interested in adoption, with additional personalization sessions also available. Informaticists partnered with departments to build department-specific order sets. (Brigham also started offering 15-minute e-learning sessions for residents.) More than 90 percent of surveyed physicians said the training met expectations, and 70 percent said they would be willing to have additional training, Landman said. Currently 5,000 physicians across Partners are trained to use voice recognition tools with the EHR.

Landman also cited a study that compared U.S. and international use of Epic that saw a huge disparity in length of documentation notes. The U.S.-based users’ notes were nearly four times longer on average than those of their international counterparts. Epic users overseas tend not to complain about the burden of documentation, he noted. This has to do with how the provider notes are used in billing, he said, adding that CMS is working on proposals to change billing requirements that may alleviate some of the documentation burden for physicians.

In closing, Landman urged informatics colleagues to think about working on EHR optimization research and studying the impact of policy and technology changes. “New technology tools can seem fun and exciting, but for physicians who see up to 100 patients per day, they can be quite overwhelming,” he said. “We don’t want physicians spending half their time doing administrative work.”

 

 

 

 

 


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