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Assisting Providers at the Point of Care: A Conversation with a Clinical Decision Support Pioneer

August 23, 2016
by Rajiv Leventhal
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Jonathan Teich, M.D., has been at the forefront of providing CDS in various forms to clinicians

Jonathan Teich, M.D., is a wearer of multiple hats when it comes to healthcare and health IT. Currently, Dr. Teich is a practicing emergency physician at Brigham & Women’s Hospital in Boston and Assistant Professor of Medicine at Harvard. But his roles in medicine don’t stop there. He’s also the chief medical informatics officer (CMIO) at Elsevier, one of the world’s biggest producers of scientific and medical information, where he works with the clinical solutions group to develop products that use sophisticated search technology and "smart content" to deliver evidence-based, actionable information clinicians can use to make decisions at the point of care.

Indeed, Teich is perhaps best known in healthcare circles for his passion around clinical decision support (CDS)—the process of delivering situation-specific, actionable health information to clinicians and patients. Most often, CDS applications—such as computerized alerts and reminders to care providers and patients, clinical guidelines, and condition-specific order sets to name a few—operate as components of comprehensive electronic health record (EHR) systems, although standalone CDS systems are also used.

To this end, Teich was on the team of authors who penned the book, Improving Outcomes with Clinical Decision Support: An Implementer's Guide, which first came out in 2005, and has since been updated periodically. In 2012, the authors published the second edition of the book, which received the Book of the Year Award from the Healthcare Information and Management Systems Society (HIMSS).

Teich believes that CDS, in various forms, “can prevent large amounts of medical errors, prevent adverse events, and can proactively optimize care.” Due to his diverse skillset in the medical field and his wealth of knowledge in health IT from spending more than 20 years in medical informatics, Teich is on the leading edge of the sector. Recently, he spoke with Healthcare Informatics about how providers can better maximize their technology investments, how CDS applications are working to help physicians right now, and what’s needed to improve. Below are excerpts of that interview.

With the huge investment the industry has put into healthcare technology, the attention is increasingly turning to maximizing the value of these systems. Is that a place where most patient care organizations sit today?


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I would certainly hope so, and I do think so. If you look at the U.S., we are at the stage in which pretty much everyone has an EHR—all the acute facilities and a large portion of ambulatory facilities—and what we are moving towards now is simply from implementation to implementation for value. Everyone is driven by payment reform and payment changes which had traditionally been based on documenting more things, but now are moving more into quality metrics and also cost of care metrics. Those things are driving payment, which is driving what people are spending money on.

Jonathan Teich, M.D.

What’s currently working, and what’s needed to maximize these investments?

There are several different areas where we need to spend more of our investment dollars to address care quality. We should be using computers’ powers to help analyze and remember everything to help us. We found research from myself and others from 20 years ago, and have reinforced since then, that clinical decision support, in various forms, can prevent large amounts of medical errors, adverse events, and can proactively optimize care. Broadly speaking, we are looking to trying to provide CDS in one form or another. And there are three or four areas that are the peak of that today.

Can you speak more about these areas?

The changes in care have to do with older patients, as there is much more chronic disease. We talk about population health and precision medicine; these are names for understanding what a patient is, what subset they fall into, knowing what the best care is for that subset, and delivering it. The areas I’m referring to are: clinical pathways, order sets and care plans, quick access to answers, analytics, and patient engagement.

Regarding clinical pathways, so much of what we’re doing is long term. We have a hard time following up on the status and needs of a 67-year-old person who has COPD [chronic obstructive pulmonary disease] and heart failure and is doing well, but needs to be kept on the straight and narrow by being monitored and having his or her treatment changed. Some people do this now with labor-intensive care management programs, but we can use computers to filter out the folks who need our attention most urgently. So if I have 150 patients with congestive heart failure, I can find ways to figure out the top six or seven who need my attention now, who are falling off a path and need a change.

A typical clinical pathway algorithm or program will help you set out a goal and an ideal path. It can provide it for you, guide you to tweak it and help you follow it. So it helps you say that if this patient’s breathing and activity is doing well, then the following is true. But if he or she showed up in the ER or had trouble breathing, then [the pathway] could help you change that too. A follower of chronic care is much better than what we’re doing now, and much better for quality and cost.

The pathway is your guiding rails, but what do I have to do when certain things happen? I need to communicate something to the patient, perhaps setting up a program where every day the patient tells me how he or she is doing in terms of breathing or weight, and I make a change in his or her prescriptions (order sets). If I think about the pathway model, patient engagement speaks to being able to understand patients’ needs and preferences, understand how they’re doing, and give them techniques to use at home and with the provider to optimize things. Maybe I ask a patient to keep a diary of his or her weight, or I do it automatically. Maybe I have a line of communication that goes to the patient every week. There is lots of education to do to keep the patient’s and doctor’s plan in line.

Some skeptics will say that clinical decision support tools haven’t realized the promise of applying knowledge in a manner that significantly improves patient care. What are your thoughts about this?

I think in some ways it’s a baby at risk of being thrown out with bathwater. If you look at the dissatisfaction that people are having with EHRs these days, a lot of that is about busy work, extra documentation, and extra process work that people have to do that they don’t feel they need to do. A lot of that is about documentation requirements and all of that stuff that we have to do for every encounter on every patient to keep track of things. I don’t think that people are opposed to CDS as long as it’s not overdone. CDS is quite well accepted, but in a world where people are annoyed by additional busy work, one has to go out of one’s way that CDS is user friendly and not intrusive.

How are CDS tools better fitting into clinical workflows these days?

People don’t want to be taken off their path or stopped when it comes to workflow. It’s okay if I get more information upfront, even more than I needed, but I don’t want to be going along with my care and then being stopped with different alerts four or five times. So we focus more on proactive means of CDS. Take something like order sets, in which you have to write orders anyway if you’re going to do prescriptions and tests. If I can give you information upfront that says here are the best orders for this kind of patient/circumstance, before I have to think about it being a change, that’s hitting my mind at a much more receptive point, and if I can do it in a way that speeds you up, people do accept that. We think that proactive pieces of CDS like those order sets, pathways, and some care plan items, are much more acceptable compared to a stream of alerts all over the place.

Can providers easily pull out what they need from these applications, or are they still going through a wealth of data?

It’s not as easy as it once was since there is so much information. There are answers to what you need out there. I know that as an ER doctor, if I see a patient that has something I’m not too familiar with, there’s an answer to it. I saw a patient recently with a case of arsenic poisoning, which I haven’t seen before, but I knew that there were answers somewhere. The question becomes, how can I get to that answer quickly?

One of the things we are spending time on now is how to optimize the search when I ask for the information, but also how to presume what I’m about to search and give me those things in the most concise, “chunkable” form that you know. Everyone likes those bits at the top of your Google page that shows you the time of your flight or the score of the game. That’s what we are seeking—to be able to give you optimized answers. We know from research that there are about 80 different questions that clinicians ask in any given circumstance. We can start to understand when you want to know those things before you do. It’s almost like a waiter who refills your drink before you’re done.

And the technology is getting better in this regard. The reason why it was hard to find information was because the growth of the huge amounts of information outpaced our ability to distill and filter it out. We spend a lot of time doing that. The technology of being able to break up information and understand information needs is just much better. We’re at the threshold now; we will see a lot more, better information quicker. And we hope to be at the forefront of that.


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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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