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AMA Immediate Past President Challenges Healthcare IT Leaders to Fix EHRs

August 11, 2016
by Mark Hagland
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Immediate past AMA president Steven J. Stack, M.D. urged healthcare IT leaders to press EHR vendors to improve their products

Speaking both as a practicing emergency physician and as the immediate past president of the American Medical Association (AMA), Steven J. Stack, M.D., challenged the healthcare IT leaders in his audience on Thursday to do everything possible to encourage improvements in electronic health record (EHR) technology for the sake of frustrated physicians, when he delivered the opening keynote address at the Health IT Summit in Nashville, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella) at the Sheraton Downtown Nashville, in Nashville, Tenn.

Speaking both of EHR technology itself, and of the meaningful use program under the HITECH (Health Information Technology for Clinical and Economic Health) Act, Dr. Stack told the assembled audience that physicians are not anti-technology; but that the immaturity of the EHR solutions available on today’s healthcare IT market, combined with the forced-march mandates embedded in the meaningful use program, have put practicing physicians in the U.S. collectively into an tenable situation when it comes to having to accept impediments to their clinical practice and workflow.

“Let’s concede that without the HITECH Act, we never would have been where we are now in terms of the adoption of EHRs,” Stack said. “Before 2008, about 80 percent of clinicians in hospitals didn’t use EHRs in any robust way. Now, only eight years later, about that percentage of doctors do.” But, he said, the federal government seems inevitably to apply very challenging “carrot and stick” mandates to physicians in practice, and the meaningful use program under HITECH has been a good example of an instance in which such a mandate has proven deeply frustrating to doctors.

“The [HITECH] law was passed in 2009,” Stack said, “and in 2009-2010, this incredible infrastructure was created for these FACA groups—federal advisory committees. It was an entire ecosystem. People have built entire careers serving on these committees. In theory, this was supposed to be a three-stage program. In the first stage, [we would] adopt EHRs and built infrastructure. In the second stage, share data. By the third stage, we would reach ‘nirvana.’ We were going to analyze and share data, and everybody was going to be happy. There was a carrot and stick element to this, as in every federal program. And the philosophy was, I will give you a dime if you spend 90 cents, and if you don’t spend the dime, I’ll start penalizing you dimes.” And that was on top of a mandate that had already been placed on U.S. physicians in 2008, when the Medicare Improvement and Patient Protection Act (MIPPA) required them to begin prescribing electronically.

Steven J. Stack, M.D. speaking in Nashville


Driving Success at Regional Health: Approaches and Challenges to Optimizing and Utilizing Real-Time Support

Regional Health knew providing leading EHR technology was not the only factor to be considered when looking to achieve successful adoption, clinician and patient satisfaction, and ultimately value...

Looking at the entirety of what has happened in the past several years, Stack told his audience, “I have to give the meaningful use program both credit and criticism. Credit, because we would not have the 80/20,” meaning that without it, perhaps only a small minority of physicians would otherwise have adopted electronic health records by now. “The criticism is that I believe we now have a mess, because we have to find a way to get a return on this investment, and we cannot get it collectively right now.” Stack asserted that the four core requirements made foundational by the meaningful use program—adopting certified EHRs, prescribing electronically, exchanging health information, and reporting quality outcomes—have been overwhelmed by additional layers of requirements. “Everything else” beyond those four core sets of requirements, he said, “for the most part is a creation of the regulatory process, not the legislative or statutory process. So what we get with meaningful use is an incredibly complex paradigm. And I would assert that a good idea poorly executed is a bad idea. And meaningful use was poorly executed.”

Stack said, “It was a good thing to get people digitized. We can book airplane tickets and hotels and just about everything else online; we couldn’t we do anything in healthcare except on paper? So yes, we have to move forward. But then,” he said, referring to federal healthcare officials, and especially the leaders at the Office of the National Coordinator for Health IT and at its umbrella agency, the Centers for Medicare & Medicaid Services, “they went too far, because they tried to use a single policy lever to remake large swaths of policy. And the frustration is such that we [clinicians] no longer care what you want to do. And we’re not blameless, either, I realize that.”

Still, Stack said, “Poor execution and poor design equals frustration at the end-user level.” And he went on to share a detailed story about one evening in April in the emergency department of the hospital where he works as an emergency physician, in which the ED’s EHR essentially froze and made all computing in the EHR impossible. The key point about the situation, which ultimately got resolved over several long hours, he said, is that “We’ve created this incredible vulnerability in our attempt to create this” important technology. “But we’ve created this single point of vulnerability through which everything must flow—in the ER.” Whether an EHR goes down because of a power outage, an “Internet glitch,” or for any other reason, he said, the reality is that it is incredibly frustrating for practicing physicians who now rely on its 24/7, 100-percent availability and reliability.

“Why is meaningful use so frustrating to doctors?” Stack asked rhetorically. “It’s because you can pass bad federal policy legislation that impacts you to some extent…but for 100 percent of your patient encounters, you must use this tool. Once you go down this path, you are never separated from this tool for every patient encounter. That’s why it’s such a pressure point and pain point for clinicians, and has frustrated physicians and nurses so much,” he said, and why downtime is simply no longer acceptable in any EHR.

Referencing a September 2014 statement from the AMA that called for a “design overhaul of electronic health records to improve usability,” Stack noted the eight “usability priorities” called for in that statement, namely that redesigned EHRs need to:

Ø  Enhance physicians’ ability to provide high-quality patient care

Ø  Support team-based care

Ø  Promote care coordination

Ø  Offer product modularity and configurability

Ø  Reduce cognitive workload

Ø  Promote data liquidity

Ø  Facilitate digital and mobile patient engagement

Ø  Expedite user input into production design and post-implementation feedback

The future, Stack said, must be towards a market of EHR solutions that are more usable, user-friendly, and reliable for physicians. He demonstrated to his audience what he meant by talking into is iPhone and asking Siri how long the drive would be from Sheraton Downtown Nashville back to Lexington, Kentucky, where he said he was about to return. Siri, in an instant, answered simply, clearly, and instantly, with the correct distance and mileage. That, he said, is the level of physician usability that the next generation of EHRs need to readily demonstrate. And he urged the healthcare IT leaders in the audience to put pressure on EHR vendors to dramatically improve the usability of every EHR solution that physicians need to interact with. Contrasting Siri’s efficiency and usability with those of the current generation of EHRs, he said, “In a world where we have smartphones and technology and are easy to use,” when it comes to EHRs, “we’ve been given things that look much more like my Atari 800 did in 1980.”

Speaking of the EHR technology that physicians are being required to use, Stack said, “I do believe it will get better. I do believe we’re going through this tunnel of despair” now, one that the U.S. healthcare system will ultimately overcome. “The problem is that we took this very immature technology and foisted it on the entire healthcare system, which is one-fifth of the economy. And the use of such immature technology, in the context of the extremely busy workdays of practicing physicians, he said, “becomes unsustainable without other efficiency and productivity benefits. I work in a fast-paced environment and make high-stakes decisions with limited information.”

In the end, Stack said of his use of EHR technology, “I love that I can look up an old EKG, I love that I can find clinical information from the past that will make a difference in my treating a patient in the ER. But when we did the 2013 survey, and we asked docs what their biggest pressure point was, over 80 percent said, EHRs. They hated their EHRs. But when we asked them, do you want to go back to paper? Over 80 percent said, no way; just make them better. I think ten years from now,” he concluded, “someone standing on this stage will be complaining about something different. The technology will be better. But I have to look to folks like you to make it better.”



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Allscripts Sells its Netsmart Stake to GI Partners, TA Associates

December 10, 2018
by Rajiv Leventhal, Managing Editor
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Just a few months after Allscripts said it would be selling its majority stake in Netsmart, the health IT company announced today that private equity firm GI Partners, along with TA Associates, will be acquiring the stake held in Netsmart.

In 2016 Allscripts acquired Kansas City-based Netsmart for $950 million in a joint venture with middle-market private equity firm GI Partners, with Allscripts controlling 51 percent of the company. With that deal, Allscripts contributed its homecare business to Netsmart, in exchange for the largest ownership stake in the company which has now become the largest technology company exclusively dedicated to behavioral health, human services and post-acute care, officials have noted.

Now, this transaction represents an additional investment for GI Partners over its initial stake acquired in April 2016, and results in majority ownership of Netsmart by GI Partners.

According to reports, it is expected that this sale transaction will yield Allscripts net after-tax proceeds of approximately $525 million or approximately $3 per fully diluted share.

Founded 50 years ago, Netsmart is a provider of software and technology solutions designed especially for the health and human services and post-acute sectors, enabling mission-critical clinical and business processes including electronic health records (EHRs), population health, billing, analytics and health information exchange, its officials say.

According to the company’s executives, “Since GI Partners' investment in 2016, Netsmart has experienced considerable growth through product innovation and multiple strategic acquisitions. During this time, Netsmart launched myUnity, [a] multi-tenant SaaS platform serving the entire post-acute care continuum, and successfully completed strategic acquisitions in human services and post-acute care technology. Over the same period, Netsmart has added 150,000 users and over 5,000 organizations to its platform.”

On the 2018 Healthcare Informatics 100, a list of the top 100 health IT vendors in the U.S. by revenue, Allscripts ranked 10th with a self-reported health IT revenue of $1.8 billion. Netsmart, meanwhile, ranked 44th with a self-reported revenue of $319 million.

According to reports, Allscripts plans to use the net after-tax proceeds to repay long-term debt, invest in other growing areas of its business, and to opportunistically repurchase its outstanding common stock.

The transaction is expected to be completed this month.

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Study Links Stress from Using EHRs to Physician Burnout

December 7, 2018
by Heather Landi, Associate Editor
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More than a third of primary care physicians reported all three measures of EHR-related stress
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Physician burnout continues to be a significant issue in the healthcare and healthcare IT industries, and at the same time, electronic health records (EHRs) are consistently cited as a top burnout factor for physicians.

A commonly referenced study published in the Annals of Internal Medicine in 2016 found that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day.

Findings from a new study published this week in the Journal of the American Medical Informatics Association indicates that stress from using EHRs is associated with burnout, particularly for primary care doctors, such as pediatricians, family medicine physicians and general internists.

Common causes of EHR-related stress include too little time for documentation, time spent at home managing records and EHR user interfaces that are not intuitive to the physicians who use them, according to the study, based on responses from 4,200 practicing physicians.

“You don't want your doctor to be burned out or frustrated by the technology that stands between you and them,” Rebekah Gardner, M.D., an associate professor of medicine at Brown University's Warren Alpert Medical School, and lead author of the study, said in a statement. “In this paper, we show that EHR stress is associated with burnout, even after controlling for a lot of different demographic and practice characteristics. Quantitatively, physicians who have identified these stressors are more likely to be burned out than physicians who haven't."

The Rhode Island Department of Health surveys practicing physicians in Rhode Island every two years about how they use health information technology, as part of a legislative mandate to publicly report health care quality data. In 2017, the research team included questions about health information technology-related stress and specifically EHR-related stress.

Of the almost 4,200 practicing physicians in the state, 43 percent responded, and the respondents were representative of the overall population. Almost all of the doctors used EHRs (91 percent) and of these, 70 percent reported at least one measure of EHR-related stress.

Measures included agreeing that EHRs add to the frustration of their day, spending moderate to excessive amounts of time on EHRs while they were at home and reporting insufficient time for documentation while at work.

Many prior studies have looked into the factors that contribute to burnout in health care, Gardner said. Besides health information technology, these factors include chaotic work environments, productivity pressures, lack of autonomy and a misalignment between the doctors' values and the values they perceive the leaders of their organizations hold.

Prior research has shown that patients of burned-out physicians experience more errors and unnecessary tests, said Gardner, who also is a senior medical scientist at Healthcentric Advisors.

In this latest study, researchers found that doctors with insufficient time for documentation while at work had 2.8 times the odds of burnout symptoms compared to doctors without that pressure. The other two measures had roughly twice the odds of burnout symptoms.

The researchers also found that EHR-related stress is dependent on the physician's specialty.

More than a third of primary care physicians reported all three measures of EHR-related stress -- including general internists (39.5 percent), family medicine physicians (37 percent) and pediatricians (33.6 percent). Many dermatologists (36.4 percent) also reported all three measures of EHR-related stress.

On the other hand, less than 10 percent of anesthesiologists, radiologists and hospital medicine specialists reported all three measures of EHR-related stress.

While family medicine physicians (35.7 percent) and dermatologists (34.6 percent) reported the highest levels of burnout, in keeping with their high levels of EHR-related stress, hospital medicine specialists came in third at 30.8 percent. Gardner suspects that other factors, such as a chaotic work environment, contribute to their rates of burnout.

"To me, it's a signal to health care organizations that if they're going to 'fix' burnout, one solution is not going to work for all physicians in their organization," Gardner said. "They need to look at the physicians by specialty and make sure that if they are looking for a technology-related solution, then that's really the problem in their group."

However, for those doctors who do have a lot of EHR-related stress, health care administrators could work to streamline the documentation expectations or adopt policies where work-related email and EHR access is discouraged during vacation, Gardner said.

Making the user interface for EHRs more intuitive could address some stress, Gardner noted; however, when the research team analyzed the results by the three most common EHR systems in the state, none of them were associated with increased burnout.

Earlier research found that using medical scribes was associated with lower rates of burnout, but this study did not confirm that association. In the paper, the study authors suggest that perhaps medical scribes address the burden of documentation, but not other time-consuming EHR tasks such as inbox management.


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HHS Studying Modernization of Indian Health Services’ IT Platform

November 29, 2018
by David Raths, Contributing Editor
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Options include updating the Resource and Patient Management System technology stack or acquiring commercial solutions

With so much focus on the modernization of health IT systems at the Veteran’s Administration and Department of Defense, there has been less attention paid to decisions that have to be made about IT systems in the Indian Health Service. But now the HHS Office of the Chief Technology Officer has funded a one-year project to study IHS’ options.

The study will explore options for modernizing IHS’ solutions, either by updating the Resource and Patient Management System (RPMS) technology stack, acquiring commercial off-the-shelf (COTS) solutions, or a combination of the two. One of the people involved in the analysis is Theresa Cullen, M.D., M.S., associate director of global health informatics at the Regenstrief Institute. Perhaps no one has more experience or a better perspective on RPMS than Dr. Cullen, who served as the CIO for Indian Health Service and as the Chief Medical Information Officer for the Veterans Health Administration

During a webinar put on by the Open Source Electronic Health Record Alliance (OSEHERA), Dr. Cullen described the scope of the project. “The goal is to look at the current state of RPMS EHR and other components with an eye to modernization. Can it be modernized to meet the near term and future needs of communities served by IHS? We are engaged with tribally operated and urban sites. Whatever decisions or recommendations are made will include their voice.”

The size and complexity of the IHS highlights the importance of the technology decision. It provides direct and purchased care to American Indian and Alaska Native people (2.2 million lives) from 573 federally recognized tribes in 37 states. Its budget was $5.5 billion for fiscal 2018 appropriations, plus third-party collections of $1.02 billion at IHS sites in fiscal 2017. The IHS also faces considerable cost constraints, Dr. Cullen noted, adding that by comparison that the VA’s population is four times greater but its budget is 15 times greater.

RPMS, created in 1984, is in use at all of IHS’ federally operated facilities, as well as most tribally operated and urban Indian health programs. It has more than 100 components, including clinical, practice management and administrative applications.


Driving Success at Regional Health: Approaches and Challenges to Optimizing and Utilizing Real-Time Support

Regional Health knew providing leading EHR technology was not the only factor to be considered when looking to achieve successful adoption, clinician and patient satisfaction, and ultimately value...

About 20 to 30 percent of RPMS code originates in the VA’s VistA. Many VA applications (Laboratory, Pharmacy) have been extensively modified to meet IHS requirements. But Dr. Cullen mentioned that IHS has developed numerous applications independently of VA to address IHS-specific mission and business needs (child health, public/population health, revenue cycle).

Because the VA announced in 2017 it would sundown VistA and transition to Cerner, the assessment team is working under the assumption that the IHS has only about 10 years to figure out what it will do about the parts of RPMS that still derive from VistA. And RPMS, like VistA, resides in an architecture that is growing outdated.

The committee is setting up a community of practice to allow stakeholders to share technology needs, best practices and ways forward. One question is how to define modernization and how IHS can get there. The idea is to assess the potential for the existing capabilities developed for the needs of Indian country over the past few decades to be brought into a modern technology architecture. The technology assessment limited to RPMS, Dr. Cullen noted. “We are not looking at COTS [commercial off the shelf] products or open source. We are assessing the potential for existing capabilities to be brought into “a modern technology architecture.”

Part of the webinar involved asking attendees for their ideas for what a modernized technology stack for RPMS would look like, what development and transitional challenges could be expected, and any comparable efforts that could inform the work of the technical assessment team.




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