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In California, Two University Health Systems Decide to Collaborate on One EHR

November 13, 2017
by Rajiv Leventhal
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UC Irvine Health’s CIO notes that this is the first time ever that two U.S. academic medical centers have linked up to be on one instance of Epic

When a health system decides to implement a new electronic record system (EHR), normally the process involves purchasing the vendor’s foundation package and then building it internally within the organization. But after careful consideration, IT leaders at University of California, Irvine Health (UCI) decided they would take a different approach to their installation of the Epic Systems (Verona, Wis.) EHR.

Indeed, for the past year-and-a-half, UC Irvine Health has been working on a project that involves the health system linking up with UC San Diego Health, another academic health system, about 120 miles away, so that the two patient care organizations would be on the same instance of Epic, rather than on separate ones. Says Charles “Chuck” Podesta, CIO, UC Irvine Health, “This is the first time that two academic medical centers in the U.S. have [collaborated] to be on one instance of Epic.” He adds, “Clearly, we went about this in a different way compared to most [other] health systems.” According to officials, the shared platform also involves a transition to a cloud-hosted environment for its medical records at Epic.

In California, there are several integrated health systems connected to major University of California organizations—the University of California, San Francisco (UCSF), the University of California, Davis (UCD), the University of California, Los Angeles (UCLA), to go along with UCI and the University of California, San Diego (UCSD). Podesta notes that each of these organizations is currently on Epic, so rather than have the fifth separate instance of Epic in the region, why not partner with one of the others? He says that they looked at UCSF, UCLA and UC Davis, but UC San Diego made the most sense based on its size and geography, being in Southern California with UC Irvine. Podesta has plenty of reasons why it makes so much sense to have a common EHR solution with another area health system, but more broadly he attests, “A lot of this is cost-based. There is just no reason in the world we should have five different IT shops among [University of California organizations] with five different instances of Epic all doing their own thing. That truly makes no sense.”

To this point, Podesta and other C-suite leaders at UC Irvine ran a cost savings analysis after looking at UCSD’s EHR system build and found that if they could align on 80 percent of UCSD’s existing build, and change 20 percent of it, “we can save a whole lot of money.” And, the implementation timeline would also be shorter, not to mention the savings with support and training, so coupled all together, Podesta says his team calculated a near $40 million cost avoidance by going with this collaborated approach. “So there was a big value proposition. But you still need to prove its [worth],” he says. “Currently we are actually at 87 percent alignment with UCSD’s build, and we have more to go post go-live, so we have met that goal.”

Agreeing on Commonalities


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Of course, when one health system decides to join another’s existing EHR build, a whole new array of challenges arise that clinical and IT senior leaders need to sort out. For one, notes Podesta, there is the shared governance aspect. “You are putting the teams together, so COOs, CEOs and CFOs across both organizations to work on governance, and to work on which [system] has the particular best practice, whatever that might be, and the best workflows, and then adopting those,” he explains. “In some cases,” he continues, “That best practice was ours, even though we were on [a different vendor’s EHR system], so UCSD would adopt it and put it into Epic, and in some cases vice versa. You can imagine how complex this is, considering how complex it is just doing this within your own organization.  But now it’s across two academic medical centers, two medical schools, research departments, faculties, etc.,” he says.  

One key strategy for UCSD and UC Irvine was to create a set of guiding principles, with one of them being that UCI would align on UCSD’s build except if it were a regulatory or patient care issue. They also agreed that the organizations would accept the best practice of each other, or of another University of California organization, such as UCSF, who UC Irvine reached out to for some of its workflows that ended up getting adopted. “Those guiding principles were front and center for every single meeting and presentation,” says Podesta. “And that’s interesting because usually they go by the wayside real quickly once you run into your first conflict or problem, or you just never bring them out at all. But we had them front and center at all times. It was so important for us to align at over 80 percent, otherwise that value proposition would be gone,” he says.

Another sign of collaboration is in the form of UCI and UCSD combining information systems (IS) support teams. Podesta says that this specific progression is in wave one of three right now, which was completed in August, and involved all of the infrastructure teams being under a single management structure across both organizations, along with security and the PMO (project management office) service desk. Wave two, which will be next spring, will be the applications part, which involves bringing in both UCI and UCSD application groups under a single leadership structure, he adds.

If those two phases go well, the third piece will be “everything else we do,” which will then lead to the two patient care systems essentially becoming one IT shop, Podesta says. “We’re a few years away from that, but by next spring we will have about 80 percent of our support structure under a single leadership structure. And we have already worked out the savings model and how the savings will be spread out across both organizations. The CEOs are excited about that,” he says.

Podesta adds that for many EHR go-lives, six months down the road, the health system will have issues, such as billing problems, and will have to bring in consultants from the outside for assistance. That, of course, leads to additional resources being spent. But in this case, “We’re talking about a savings rather than adding more resources post go-live,” he says. “My whole team has been working on Epic for over a year, so now they’re part of the implementation and support, along with UCSD.”

Christopher Longhurst, M.D., CIO, UC San Diego Health, added in a prepared statement, “This groundbreaking collaboration aligns with the broader strategic goals of UC Health to share services and generate efficiencies across campuses through shared implementation and maintenance of technology platforms. Through this process, we’ve aligned our clinical pathways and practices to leverage the best of both organizations.”

Adapting in the Era of the Pressured CIO

Podesta points out this type of collaboration project would be unheard of even just three or four years ago, but with new pressures on CIOs to save money while also thinking about next-level population health strategies, it became something of a no-brainer for UC Irvine. “We are teaming up on some population health [initiatives] where having a single EHR will benefit us greatly when we hit those populations. So it’s morphed into a strategic imperative rather than an EHR go-live, and that’s how the CEOs view it,” he says.

Podesta notes that when he talks to his peers about this, most don’t think that they can do a collaboration of this significance in their region with the next-door neighbor health system. “But I tell them that they have to; costs will simply get too high.”

And then there’s also the competitive standpoint. Podesta points out that CIOs are saying that their jobs are hard enough in their own organizations, so they can’t imaging sticking their necks out proposing something where shared governance and the complexity around that will need to be created, and also the relationships that will need to be built across two organizations. “It’s just very difficult,” he attests. “Even with M&As happening, they struggle with being able to put this all together, and in those cases, one organization actually owns the other. And they still struggle!”

Nontheless, Podesta thinks that for many regions, this type of partnership “is the model of the future.” And the idea is for this to be scalable and in time, if UCI and UCSD indeed “pull it off,” there will be pressure on the other university health systems in the area to do something similar. “I think it will happen over time, but it will take a while. We have to show the cost savings first,” he says.

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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.

Related Insights For: EHR


Montana Senator to VA CIO: “EHR Modernization Cannot Fail”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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Senate VA (Department of Veterans Affairs) Committee Ranking Member Jon Tester has urged new VA CIO James Gfrerer to avoid past failures as he helps to move forward the department’s EHR (electronic health record) modernization project.

Gfrerer, an ex-marine and former executive director at Ernst & Young, was recently confirmed by the Senate to serve as assistant secretary of information and technology and CIO (chief information officer) at the Department of Veterans Affairs.

One of Gfrerer’s top tasks will be helping to update hospitals’ infrastructures as the VA continues to work on replacing the department’s 40-year-old legacy EHR system, called VistA, by adopting the same platform as the U.S. Department of Defense (DoD), a Cerner EHR system. That contract was finally signed last May and the implementation project is scheduled to span over 10 years.

In a letter to Gfrerer, Tester, a Montana senator, noted that while many of the responsibilities for the implementation of VA’s new EHR fall to the recently created Office of Electronic Health Record Management, the CIO’s role “is critical to ensure that we do not repeat the mistakes of the past.”

The office that Gfrerer now leads, VA’s Office of Information and Technology, will still be in charge of managing infrastructure needs for both the patient care facilities that have received the EHR upgrades and those that have not, Tester stated. “This task will require significant resources and robust oversight as VA manages a decade-long rollout,” he said.

Tester further wrote, “EHR modernization cannot be allowed to fail, and your leadership is essential if VA is to ultimately achieve a truly interoperable health record for veterans.”

In regard to “past failures,” it’s possible that Tester is referring to media reports that have outlined some of the significant issues that the DoD has had with its own Cerner rollouts. In reports throughout 2018, the initial feedback on the four military site EHR rollouts has been less than ideal. A Politico report first detailed the first stage of implementations noted that it “has been riddled with problems so severe they could have led to patient deaths.” Indeed, some clinicians at one of four pilot centers, Naval Station Bremerton in Washington, quit because they were terrified they might hurt patients, or even kill them, the report attested.

Providing an update on Cerner’s progress with the DoD EHR implementations, a company executive recently noted that he is seeing “measurable progress” at the DoD’s initial operational capability (IOC) sites.

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