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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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UnitedHealth Group Plans to Unveil Health Record for Members, Providers in 2019

October 17, 2018
by Rajiv Leventhal, Managing Editor
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Health insurer UnitedHealth Group will be unveiling a “fully integrated and fully portable individual health record,” CEO David Wichmann said on the on the company’s third-quarter earnings call yesterday.

Speaking to the insurer’s broader digital health strategy, Wichmann stated on the earnings call that the company’s consumer digital health platform, Rally—which is a website and mobile app—is now serving over 20 million registered users and will leveraged to help develop the health record.

“Rally is synthesizing information and engaging people to better manage their health, helping consumers save money by selecting the highest quality care providers, understanding their out-of-pocket costs up front, and in some markets even scheduling appointments for care. We will soon be releasing at scale a first-of-kind, fully integrated and fully portable individual health record that delivers personalized next-best health actions to people and their caregivers,” Wichmann said on the call.

While many more details are not yet known about the health record, Wichmann did say that by the end of 2019, the insurance giant has the goal of developing individual health records for the 50 million fully benefited members that it serves, as well as for their care providers.

He noted, “We would use the Rally chassis…to provide individuals in a way in which they can comprehend a tool, if you will, not only outlining their individual health record, but also giving them next-best action detail. That's what I mean by when I say it's deeply personalized. It's organized around them, not based upon generic criteria. It also assesses to what extent that they've been, and how they've been served by the health system broadly, and whether or not there's been any gaps in care that have been left behind.”

Giving a little bit more information about the vision UnitedHealth Group has in regard to the health record, Wichmann said, “You might imagine what that could ultimately lead to in terms of a continuing to develop a transaction flow between the physician and us and the consumer and us, as we us being the custodian to try to drive better health outcomes for people, but also ensure that the highest level of quality is adhered to.”

UnitedHealth Group already has its Optum business line, a health innovation company that provides health services in an array of different ways, including through its growing data analytics capabilities.

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UC Davis Health’s Physician-Specific Approach to Addressing Burnout

October 16, 2018
by Rajiv Leventhal, Managing Editor
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To combat the physician burnout epidemic, one health system is taking matters into its own hands

Physician burnout has long been a significant healthcare challenge, but in recent years with the advent of various technologies into clinical workflows, along with an array of regulatory requirements, the problem seems to be getting worse.

Indeed, there is no shortage of research that backs up the notion that physicians are overburdened, with some surveys having found that 30 to 60 percent of clinicians report symptoms of burnout, which can threaten patient safety and physician health. What’s more, EHRs (electronic health records) are consistently cited as the top burnout factor, largely due to the time one must spend in them documenting and performing other administrative tasks. To this point, 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.

Although federal health officials have been outspoken about the need to combat these issues while improving physician satisfaction, some hospitals and have health systems have been taking matters into their own hands. In Sacramento, not long ago, clinical and IT leaders at the University of California, Davis (UC Davis) Health were eager to get funding to develop and roll-out a program to improve physician efficiency levels within the EHR.

Scott MacDonald, M.D., the health system’s EHR medical director, says that in order to get that funding, his team needed to show the organization’s leadership, via a pilot project, that a program designed around improving physician efficiency in the EHR was worthwhile and valuable. They ended up getting a small team together, mostly volunteers from various UC Davis Health locations, and piloted two high performing clinics and two low performing ones, based on efficiency data from Epic, MacDonald recalls.

In order to determine which clinics were doing well with their EHRs, and which ones were not, the UC Davis Health team looked at a number of factors. For one, they would examine a given individual physician to see if he or she was spending more than the average amount of time on certain EHR “in-basket” tasks, explains MacDonald. “We would then look and compare that data to others in that physician’s department and specialty to see if there were outliers. So that’s a useful tool for us to recognize that this person is efficient with chart reviews but inefficient with writing notes, [for example].”

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For years, healthcare institutions have attempted to manage paper documents and electronically captured PDF files. These documents can be electronically stored in various databases like EHRs, ERPs...

MacDonald says that they would also survey the physicians to see what they personally feel they are most inefficient with in the EHR. “We wanted to make sure that we address their biggest areas of frustration,” he says, noting that the organization is also looking to add a chief wellness officer to help accomplish this.

Problems in the Trenches

MacDonald says that his team, based on anecdotal conversations with physicians, believes that it’s “patently obvious that doctors are frustrated by EHRs and IT, as well as the other factors from the changes in the healthcare system over the last few years, as well as the regulatory environment.”

That said, MacDonald doesn’t believe that EHRs are hurting the physician-patient relationship; more so that they are “blamed” for hurting it. “Because of what’s happened over the course of the last decade, with lots of regulatory requirements, even going back to the 1990s with CMS [the Centers for Medicare & Medicaid Services] billing regulations, all those things have been addressed in a lot of organizations through the EHR. So people tend to shoot the messenger and blame the EHR for these ills. But the EHR is really just a tool, and if that tool is built and trained well, it’s certainly a real boon to the quality of care we deliver,” he says. “If people know how to use the tool effectively when they are seeing a patient, [it will] become a partner in the care with the patient, rather than a mediator of the care,” he emphasizes.

Providing some more context, MacDonald believes that if doctors have the computer screen up between them and the patient, and all the patient sees are the wires coming out of the back of the monitor, that doesn’t make for a good experience for the patient. “But if you are in a triangle with the patient and the monitor, and you are engaging the patient in the data you are looking at, then it could be a real positive. Across the U.S., we have not trained our physicians in that aspect of modern medicine. How we use the tool is part of the relationship with the patient,” he says.

A Program Designed for the Physician

UC Davis Health’s Physician Efficiency Program (PEP), modeled after the pilot project in the four clinics last year, tapped program manager Melissa Jost, who oversees six analysts. Teams of three are deployed to clinics to train and build features within the Epic EHR platform. What’s more, Jost supervises two builders and four trainers, an approach that MacDonald believes makes this program particularly unique. “We integrate the building and training in one team. So when we go out to the clinics and work with [physicians], we can not only show them how to use the tools that exist, but also build the tools if one doesn’t exist and there is something that is workflow-specific that’s needed.”

Each team spends up to six weeks in a clinic monitoring workflows, reviewing EHR-use metrics and working one-on-one with each physician to personalize and optimize their use of EHR tools. Clinics also reduce each physician’s patient schedule by 50 percent to allow time for the training sessions right in the clinic during normal clinic hours, with team members also available for follow-up questions or sessions on site, according to officials, who also note that the goal is to engage all primary and specialty care ambulatory physicians by 2020.

MacDonald admits that to date, the data isn’t perfect, but it gives his team broad strokes about how effective individuals, clinics and groups are using the EHR system. Nonetheless, officials point to some encouraging results from the program—namely a 12-percent increase in physician satisfaction, 24-percent increase in physician efficiency, and an average reduction of 25 hours less per month in time spent working after hours per physician trained.

And in terms of anecdotal physician feedback, MacDonald says that they love the program so far. “We have been getting rave reviews,” he notes, noting that he recently asked physicians at one clinic their feelings about the program and how it can improve, to which the near universal response was, “When are you coming back?”

When asked if physicians feel that the core problem with EHRs is the documentation requirements, or technical flaws in the systems themselves, MacDonald chalks it up to a “mix of everything.” He says that this type of tension is common in informatics, and people ask, “Why can’t Epic just do [X]?” But MacDonald notes that oftentimes the system actually can do that thing and the physician might not know how to do it. “Often, people’s frustrations can be easily met with simple training because the tools are already there from the vendor. But that’s not always the case, and that’s why we do additional build work to customize it,” he says.

MacDonald adds that in healthcare, there is always this “undercurrent of external requirements that don’t appear to people to have much clinical value,” such as reporting on quality measures, data collection, and regulatory requirements, but most physicians do reluctantly accept the necessity of these things by working in the modern healthcare system. “But if we can mitigate [the burden] by giving them a faster way of doing it, they will appreciate it,” he says.

 


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Report: athenahealth Has Multiple Bidders for Sale of the Company

October 15, 2018
by Heather Landi, Associate Editor
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Watertown, Mass.-based health IT company athenahealth has attracted interest from at least five potential bidders for a possible sale of the company, people familiar with the matter told Bloomberg.

In an article posted Friday, Bloomberg reports that private equity players including Bain Capital, Hellman & Friedman, Clayton, Dubiliar & Rice and TPG are considering bids for athenahealth, the people said, asking not to be identified because the matter is private. Elliott Management Corp., the sometimes-activist fund run by billionaire Paul Singer, is also weighing a bid, people familiar with the matter told Bloomberg.

Elliott, which owns 9 percent of athenahealth, may keep that stake if it is unsuccessful in acquiring the company, the people said.

“athenahealth has received indications of interest above $135 a share, the people said, with final bids due by the end of the month,” Bloomberg reported.

As previously reported by Healthcare Informatics, in May, Elliott Management made an all-cash takeover offer to buy athenahealth, at a valuation of $6.9 billion. The investors sent a letter to athenahealth’s board proposing to acquire the company for $160 per share. In the letter, the investors criticized leadership at the electronic health record (EHR) vendor for failing to make the changes necessary “to enable it to grow as it should and to create the kind of value its shareholders deserve.”

The story continued to take turns throughout the summer, particularly following the resignation of CEO and President Jonathan Bush in June. Bush’s resignation came just a few weeks after Elliott Management’s takeover bid, and just a few days after reports surfaced that the athenahealth chief had allegedly assaulted his ex-wife more than a decade ago, and also created a “sexually hostile environment” at the company.   

Following the news, various companies, both inside and outside of healthcare, were brought up as possibilities to buy athenahealth, including the Kansas City-based EHR giant Cerner Corp.

According to a report in the New York Post published in early September, Elliott Management was cited as the favorite to win the athenahealth takeover bid, reporting that Cerner and UnitedHealth declined an opportunity to acquire the health IT company.

The Sept. 6 report noted that “The healthcare companies that would most logically be interested in athenahealth, including Cerner Corp. and UnitedHealthcare, have taken a pass…” As such, Elliott has now teamed up with investment firm Bain Capital on its bid, the New York Post noted at the time.

Bain Capital owns Waystar, a healthcare technology company that was recently formed by combining Navicure and ZirMed, two revenue cycle management vendors. Waystar may benefit if Bain buys athenahealth, an industry banker told the New York Post.

However, almost two weeks later, another report in the New York Post indicated that Elliott Management had backed away from its $160-a-share bid for athenahealth. “As a result of Singer’s retreat and the lack of robust interest from others, athena has extended a final bid deadline by 10 days — to Sept. 27, sources said. Singer backing off the promised bid is a stark turnaround in the battle for the health care tech company,” the New York Post article stated.

According to an October 11 article in the New York Post, suitors whose offers were deemed too low months ago are being invited to take a second look, according to sources. Bids are now believed to value the company at no greater than $135 a share.

“athena first sought final bids by a Sept. 17 deadline. Then, it extended that deadline by 10 days. Now, the company will likely not make a decision until next week at the earliest on how to proceed, two sources said,” according to the article.

“The seller is deciding between a full sale, a merger with Pamplona Capital’s NThrive or to continue as a listed company,” the New York Post article reported.

The New York Post article also reports that if the company decides not to sell or merge, it will have to find a new CEO to replace Bush, sources said. Former GE chief Jeff Immelt has been running Athena as its executive chairman since the summer.

“They definitely need a CEO that is not Jeff Immelt,” the analyst said in the article. “If I’m the candidate, I would want to know what Elliott’s perspective is going forward.”

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