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Clinicians to CMS, ONC: “Right the Ship” to Simplify Reporting, Ease Regulatory Burdens

February 23, 2018
by Heather Landi
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During a daylong listening session sponsored by federal healthcare and health IT officials focused on the issue of reducing clinician burden, healthcare industry stakeholders—physicians, nurses, patient advocates and entrepreneurs—shared a litany of frustrations and complaints about electronic health records (EHRs) systems adding to administrative burden and contributing to physician burnout.

Officials with the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC), both within the U.S. Department of Health and Human Services (HHS), got an earful from clinicians and other stakeholders about poor health IT workflows and the challenge of keeping up with government reporting requirements. The listening session took place in person in Washington, D.C., as well as via telephone.

One semi-retired practicing physician said that in the process of adopting health IT and EHRs, the healthcare industry’s focus has shifted from the patients to billing. “I’ve been through four different EHRs in my time, and what we failed to do in all that process, is that we failed to keep patients at the center of that process. At the end of the day, we are either typing or using natural language processing (NPL) or clicking boxes and patients don’t get anything out of that. They get us looking at our computers,” he said. “We have to get back to keeping it simple.”

The physician, who said he has been practicing for 26 years, also said, “Everything we’ve built is about how we get paid and how do we protect how we get paid. I’d like to see us build something in NPL, so that with the aging population, that patient can get that record and have some autonomy and you can give that record to a family member; put that patient at the center of what we are doing.”

Clinicians raised a number of issues related to “note bloat,” the lack of interoperability, inaccurate medication lists and too much reporting. One clinician cited the “tremendous broken promise around interoperability,” as an important issue for the health IT industry to focus on. “The return on investment promised with creating an EHR was that we would finally have data liquidity; the information we needed to take care of patients at the point of care would be available. That has never happened. I’m still exchanging faxes between hospitals and other providers; the electronic transmission of information that was supposed to create a seamless process hasn’t happened.”


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One patient advocate, who said she has been living with chronic disease for 40 years, said bluntly, “The systems you are forced to use suck and don't do what they're supposed to be doing.”

Another physician urged CMS officials to simplify reporting requirements: “The right thing to do is the simple thing; focus technology on the data needed for care, it’s not about the secondary uses of data, including reporting to federal agencies. CMS has an opportunity to simplify Meaningful Use for hospitals and an opportunity now to right the ship and look at, are you doing the right thing as opposed to having a lot of checked boxes.”

Based on the comments, it’s clear that many clinicians are fed up with current EHR systems, and many suggested scrapping legacy systems altogether and focusing instead on consumer-facing technologies and open application programming interfaces (APIs). One physician said, “We, as a group, need to think about some of the solutions that are already out there and maximize them. Stop thinking about legacy systems; we don’t need to be here, we can start over. It will be challenging, but where we are right now is a sinking ship situation. We should optimize the solutions used by our patients every day. There are these other programs that we could be utilizing to improve patients’ health and improve the life of physicians.”

One cardiologist noted that the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the 21st Century Cures Act were steps in the right direction regarding aligning reporting requirements, but more work needs to be done. “There is a lot of complexity that is confusing. MU (Meaningful Use) was rolled into QPP (Quality Payment Program), and other programs that still exist, so it’s incredibly confusing and we use a multitude of standards and requirements that are not aligned. CMS and ONC need to align some of these existing programs to help to reduce administrative burden and the complexity of these programs.”

Opening up the listening session, Kate Goodrich, M.D., chief medical officer at CMS, said the purpose of the public listening session was to gather stakeholder feedback about administrative and reporting burdens from health IT, which will then inform the agency’s efforts to make life easier for clinicians.

“We’ve been trying to engage with our provider and patient and other stakeholder partners pretty intensively to hear from you all about the specifics of the things that CMS could be doing and other parts of the department to reduce administrative burden on providers, while maintaining safety for patients and better health outcomes for patients,” she said.

At the end of the listening session, John Fleming, ONC deputy secretary for reform, said, “We’ve heard your suggestions, and the bottom line is, we want to improve patient care quality and reduced the cost of care, and that’s a difficult equation to come to. Health IT offers a number of potential solutions to our problems, but right now it’s creating a lot of burden.”

Fleming classified the issues into four priorities moving forward—streamlining documentation, getting EHR-based preapprovals for tests, referrals and medications; reducing the burden of quality reporting, and improving prescription drug monitoring programs (PDMPs) for controlled substances.

Andy Gettinger, ONC’s chief medical officer, said, “I don’t believe our work will be done until the EHRs and other health IT tools are things that clinicians who are taking care of patients can’t imagine taking care of patients without, because they need them. We haven’t gotten that sense today. We have work to do, collectively, not just government.”

CMS and ONC officials urged healthcare stakeholders to continue to provide input on clinician burden from health IT by emailing comments to this address:

CMS and ONC officials also highlighted ongoing work to address regulatory and administrative burden, such as documentation requirements, relating to the use of EHRs. CMS officials pointed to the steps being taken as part of the Patients Over Paperwork initiative, such as ending a requirement that doctors re-write medical students' notes in EHRs. CMS officials said CMS Administrator Seema Verma is focused on simplification of documentation requirements, including getting rid of requirements no longer needed and making requirements easier to understand.

 A team led by ONC’s Gettinger and CMS’s Goodrich are collecting feedback and suggestions from providers and the team has developed clinician burden workgroups to further investigate the issue. The workgroups focus on topics such as documentation, administrative and reimbursement models, EHR reporting, health IT and user-centered design and non-federal payers and other government requirements. HHS may consider regulation and sub-regulatory measures, Gettinger said.

Goodrich stated that 2018 “is going to be a big year” for sub-regulatory activities.

When it comes to health IT usability, EHR workflows seem to be top of mind for many clinicians. During audience polling on a number of health IT issues, a little more than half of the audience cited alignment of the clinical and EHR workflow as the most pressing EHR usability issue. When asked what ONC should do to help drive usability improvements, close to 60 percent said they’d like to see more substantial changes requiring adherence to certain agreed upon usability standards and best practices.

When asked about the most burdensome aspect of using health IT for clinical care, clinicians and other stakeholders in the audience were evenly split between documentation requirements and lack of interoperability (each cited by about 35 percent of the audience).

The audience also was polled about ways that CMS could reduce EHR-related burden associated with documentation of patient visits for billing. Half of the audience would like to see CMS not require documentation if the information already exists in the record, and about 40 percent would like to see CMS explore alternative documentation strategies for reimbursement which do not rely on prescriptive documentation requirements.


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Report: Apple in Talks with VA to Provide Veterans Access to EHRs

November 21, 2018
by Heather Landi, Associate Editor
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Tech giant Apple is in talks with the U.S. Department of Veterans Affairs (VA) to provide portable electronic health records (EHRs) to military veterans, according to a Wall Street Journal report published Tuesday.

According to people familiar with the effort and emails reviewed by WSJ, under the plans being discussed Apple would create special software tools allowing the VA’s estimated nine million veterans currently enrolled in the system to transfer their health records to iPhones and provide engineering support to the agency, the article says.

In January, Apple announced that it was launching a feature that allows consumers to see their medical records right on their iPhone and began testing the Health Records feature out with 12 hospitals, inclusive of some of the most prominent healthcare institutions in the U.S. Since that time, more than 100 new organizations have joined the project, according to Apple.

According to the WSJ article, top VA officials, as well as associates from President Trump’s Mar-a-Lago Club, discussed the project last year in a series of emails reviewed by the Journal. The emails show how the Trump administration wrestled early on with the project’s goals, the article says. An Apple spokeswoman said the company has nothing to announced, according to the article.

Technology companies are looking to tap into the $3.2 trillion health care market. Google recently tapped Geisinger Health System CEO David Feinberg, M.D. to assume a leadership role over its healthcare initiatives. Amazon, JPMorgan Chase & Co. and Berkshire Hathaway have formed a healthcare joint venture and tapped Atul Gawande, M.D., as CEO of the initiative.

“The VA partnership has the potential to accelerate Apple’s efforts to overcome past challenges by allowing it to tap into one of the nation’s largest, concentrated patient populations,” the WSJ article states. To date, Apple has had to take a more patchwork approach, signing agreements with hospital networks and relying on them to encourage patients to import their medical records to iPhones using the new Health Records feature.

WSJ reporters Ben Kesling and Tripp Mickle wrote, “The company’s ultimate goal is to enable patients to import their records and share them with health-related apps, which would use data to provide services like automated prescription refills, according to people familiar with Apple’s plans.” Apple would take a 15 to 30 percent cut of those subscriptions as it does with most apps offered through its App Store, Kesling and Mickle wrote.

According to Kesling and Mickle , Apple first approached the VA in early 2017, citing a person familiar with the effort. Company and VA officials were excited about the project’s promise because it would allow true interoperability and portability of health data between doctors and software platforms, the person said, according to the article.

“Apple and the VA were developing the technology among a relatively small group of experts and officials, which required non-disclosure agreements, according to an email reviewed by the Journal from Darin Selnick, a senior advisor to the VA secretary at the time,” the article says.

Some of the early discussion involved Dr. Bruce Moskowitz, a doctor affiliated with Trump’s Mar-a-Lago golf club, who wasn’t a government employee and has no official role at the VA, the article says. “Dr. Moskowitz laid out a series of goals for the technology early in the process, including the ability for veterans to find a variety of health care facilities near them by using geotagging features and to quickly share test results and track prescriptions,” the article states.

Moskowitz also envisioned a system that would allow active duty troops to take advantage of the technology, another potentially massive patient base, the article says. At the time, VA officials stated in emails that they were most interested in focusing on doctor certifications, patient control of data and development of a suicide-prevention app, according to the article.

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VA, Cerner Leaders Detail Progress on EHR Implementation, Interoperability Efforts

November 14, 2018
by Heather Landi, Associate Editor
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The U.S. Department of Veterans Affairs (VA)’s new $16-billion-dollar Cerner electronic health record (EHR) system will use open application programming interface (APIs) and Fast Healthcare Interoperability Resources (FHIR) standards to enable interoperability with the private sector, according to a Cerner executive, which potentially positions the VA as a leading force to drive interoperability forward in the healthcare industry.

The ability of the VA’s healthcare system to seamlessly share patient data with the U.S. Department of Defense (DoD) as well as health systems and physicians in the private sector continues to be a top concern among Congressional leaders as the VA is now six months in to its implementation of a new Cerner EHR, and the topic dominated a House oversight subcommittee hearing on Wednesday.

Congressional leaders pointed out that interoperability between VA and DoD and between VA and community providers would be key to the success of the VA electronic health record (EHR) modernization effort. “If you can’t make that step work, then this won’t work,” Rep. Phil Roe, M.D., (R-Tenn.) chairman of the House Veterans Affairs committee, said.

During the hearing, members of the House Veterans Affairs' technology modernization subcommittee reviewed the electronic health record modernization (EHRM) program’s accomplishments, to date, and questioned VA and Cerner leaders about implementation planning, strategic alignment with the DoD’s MHS Genesis project, as DoD also is rolling out a new Cerner EHR, as well as interoperability efforts.  

The VA signed its $10 billion contract with Cerner in May to replace VA’s 40-year-old legacy health information system—the Veterans Health Information Systems and Technology Architecture (VistA)—over the next 10 years with the new Cerner system, which is in the pilot phase at DoD. The VA project will begin with a set of test sites in the Pacific Northwest in March 2020.


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In October, the U.S. Secretaries of the VA and DoD signaled their commitment to achieving interoperability between the two agencies by implementing a single, seamlessly integrated EHR, according to a joint statement both agencies issued. VA Secretary Robert Wilkie and Defense Secretary James N. Mattis signed a joint statement Sept. 26 pledging that their two departments will “align their plans, strategies and structures as they roll out a EHR system that will allow VA and DoD to share patient data seamlessly."

However, subcommittee chairman Jim Banks (R-Ind.) noted during the hearing, “Community provider interoperability has always been the elephant in the room. VA-DoD interoperability is very important, but VA is further behind in exchanging records with its community partners. There are helpful tools, such as health information exchanges (HIEs), but no out-of-the-box EHR system completely solves this problem.” Banks added, “Community interoperability is a very real problem, and for $16 billion, VA had better solve it.”

It is estimated that up to a third of VA patients receive care in the private sector.

"I’m not ready to sound the alarm, but I’ve heard very little on the subject [interoperability with DoD and community providers],” Banks said, noting that a review by industry experts indicated that VA and DoD need to be on the same instance of the Cerner EHR in order to achieve seamless interoperability. “That means both departments have to pull patient data from the same database. The two implementations have to be joined at the hip. It raises the stakes. It’s important to put this reality out in the open, and early.”

During her testimony, Laura Kroupa, M.D., acting chief medical officer with the VA’s Office of Electronic Health Record Modernization (OEHRM), noted that interoperability with community healthcare providers was a challenge that VA and Cerner leaders were working together to address.  “Going on the Cerner platform will allow us to utilize national systems in place for interoperability. Our community care councils also look at all the different workflows for how patients get referred into and out of the VA to make sure that information is exchanged and put into the system, not just as a piece of paper or image, but actually the data itself,” she said. Kroupa said project leaders are working to utilize interoperability mechanisms that Cerner currently has as well as HIE initiatives already in place, such as Carequality and CommonWell, to ensure interoperability between VA and the private sector.

John Windom, who leads the VA’s EHR modernization project as the executive director of VA’s OEHRM program, said, “There are two issues—one is technology-based which is solved, the HIEs, CommonWell, Carequality, allow seamless exchange of information. But, there is also another piece, the information has to be put in, and so that information has to be made accessible by the people on those networks; we’ve got the technology piece solved.”

Travis Dalton, president of government services at Cerner, testified that Cerner would use open APIs and FHIR-based integration to enable interoperability between VA and healthcare providers in the private sector.

“We’ve committed to that contractually. It’s going to happen, it’s technically possible and feasible,” Dalton said, adding, “What will be powerful to the industry and commercial partners is if VA and DoD choose a common standard. That will move the industry forward because this isn’t always a technical issue, it’s a standard-based issue. The power of the DoD and VA to make that choice to move it forward will influence the commercial marketplaces. The tools exist, through HIE and Direct exchange; it’s a standards issue.”

Congress created the technology modernization comittee to provide more rigorous oversight of the project amid concerns about the project’s cost and alignment with the defense department’s electronic health record roll-out.

There have been ongoing questions about VA leadership, specifically with regard to the EHR modernization project, beginning with the ouster of the previous VA Secretary, David Shulkin, M.D., earlier this year, as well as other shake-ups, including the resignation of Genevieve Morris only two months after she was tapped to lead the VA’s EHR project.

An investigation by ProPublica, detailed in a report published Nov. 1, asserts that VA’s EHR contract with Cerner has been plagued by multiple roadblocks during the past year, including personnel issues and changing expectations. According to that report, Cerner rated its EHR project with the VA at alert level "yellow trending towards red.” To investigate the underlying factors that have contributed to the EHR project's problems, the publication reviewed internal documents and conducted interviews with current and former VA officials, congressional staff and outside experts.

In parallel, Rep. Banks has expressed concerns with the VA’s “apparent loss of focus” on innovation, specifically as it relates to open APIs. In a letter to acting VA Deputy Secretary James Byrne dated Oct. 10, Banks noted that two years ago the VA initiated an open-API gateway interoperability platform concept, called Lighthouse. Back in March, during the HIMSS Conference, the VA also announced an open API pledge, with the launch of a “beta” version of its Lighthouse Lab, which offers software developers access to tools for creating mobile and web applications to help veterans better manage their care, services and benefits. Banks wrote that these efforts seem to have “lost momentum.”

In the letter, Banks noted that the VA needs a flexible platform to translate data coming in from multiple EHRs and on which to build, and so its private sector partners can build, interfaces to and from medical practice billing systems, insurance companies, external applications, veterans’ devices and one day Medicare and Tricare’s systems. “The need to ‘future-proof’ the technology that VA is acquiring is very real. Moving forward with the open-API gateway and sustaining the open API pledge are important steps to do that,” Banks wrote.

Progress Made in the First 180 Days

During the hearing, Windom outlined the EHRM program’s accomplishments, to date, including the establishment of 18 workflow councils and current state assessments of the initial implementation sites. VA and Cerner project leaders also completed an analysis report to assess the DoD’s MHS Genesis system as EHRM’s baseline. The workflow councils are mostly comprised of clinicians in the field who provide input to enable configuration of national standardized clinical and operational workflows for the VA's Cerner EHR system, Windom said.

Dalton said the site visits of the initial implementation sites provided important insights into VA’s IT needs. “VA has a unique patient population, you’ve got an older, sicker population, with unique needs, such as behavioral health. Some areas that we uncovered that we need to focus on now include telehealth, behavioral health and reporting. These are big content areas,” he said, adding, “I expect the work that we do will help to lead us into the future in that area. We expect that as we work closely together to meet the needs of the agency that will help to makes us better commercially.”

Dalton said the VA Cerner are committed to applying commercial best practices, as well as any lessons learned from our DoD experience, to the VA’s EHRM program.

“We learned some hard lessons with the DoD experience,” he said. “Transformation is always difficult. We’re doing things a lot differently—we’re engaging with sites early and often. We’re also doing more workshops up front, so it’s more of an iterative process.” And, he added, “This is a provider-led process. We have the 18 councils that are assisting us with validation of the workflow.”


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