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CMIO/CHIO Summit: Managing Clinical Decision Support and Improving Workflow

December 27, 2016
by Trudy Millard Krause, UTHealth School of Public Health
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The Scottsdale Institute CMIO/CHIO Summit set out to foster collaboration among chief medical information officers and chief health information officers from prominent healthcare systems across the country

Executive Summary: Twenty chief medical information officers (CMIOs) and chief health information officers (CHIOs) of leading health systems gathered in Chicago this past fall to share best practices and lessons learned regarding clinical decision support (CDS) and improving clinical work flow. This report captures their discussion and shared insights.

Summit participants: David Classen, M.D., Pascal Metrics and University of Utah; Greg Forzley, M.D.,  Trinity Health, Anupam Goel, M.D., Advocate Health Care, Greg Hindahl, M.D., BayCare Health System; Kim Jundt, M.D., Avera Health; Michael Kramer, M.D., Spectrum Health; Michele Lauria, M.D., EasternMaine Healthcare Systems; Thomas Moran, M.D.; Northwestern Medicine; Nnaemeka Okafor, M.D., Memorial Hermann Health System; Theresa Osborne, M.D., Spectrum Health; Jerry Osheroff, M.D., TMIT Consulting, LLC, Luis Saldana, M.D., Texas Health Resources; Anwar Sirajuddin, Memorial Hermann Health System; Andy Spooner, M.D., Cincinnati Children’s Hospital Medical Center; Peter Springsteen, M.D., Munson Healthcare; Pete Stetson, M.D., Memorial Sloan Kettering Cancer Cente; Jeffrey Sunshine, M.D., University Hospitals; Randy Thompson, M.D., Billings Clinic; Paul Veregge, M.D., Catholic Health Initiatives; Alan Weiss, M.D., Memorial Hermann Health System

Organizer: Scottsdale Institute; Sponsor: Deloitte; Moderator: Deloitte (Ken Abrams, M.D.)

Introduction: The Scottsdale Institute CMIO/CHIO Summit was held in Chicago on September 30, 2016. The objective of the Summit was to foster collaboration among chief medical information officers (CMIOs) and chief health information officers (CHIOs) from prominent healthcare systems across the country, with the intention of learning from shared experiences, best practices and proven approaches.

The group was tasked with reviewing the maturity of the clinical decision support (CDS) processes within organizations that responded to a pre-summit survey. Based on those findings a productive discussion evolved regarding CDS and lessons learned. Future visions and emerging trends and technologies were explored, along with the impact to CDS and the CMIO/CHIO role. The impact of future payment policies such as MACRA and bundled payments on information systems was also explored.

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Throughout the Summit, underlying themes stressed the importance of CDS in patient outcomes, physician performance, organizational quality metrics and, ultimately, reimbursement strategies. This critical component thereby requires organizational commitment and support along with evolving strategies for system improvement and sustainability to meet future demands and opportunities.

Pre-Summit Survey Results

In advance of the summit, the Scottsdale Institute circulated a survey among CMIOs and CHIOs regarding CDS with the intention of collecting information to initiate fact-based discussion during the summit. The survey was written by Dr. Michael Kramer, Dr. Nnaemeka Okafor, Dr. Luis Saldana, Dr. Anwar Sirajuddin and Dr. Alan Weiss. Twenty-two responses were returned. The responses indicated there were varied levels of maturity in CDS implementation and design. A summary of responses follows:

> The most frequently identified knowledge-management system used for CDS was an EHR tool such as Epic or Cerner, but other responses reported using tools such as Word, Excel, Tableau or others.

> CDS project-management initiatives were most frequently organized by steering committees or councils, but the majority of responses varied greatly.

> 59% of respondents reported that the CDS elements were not reviewed on a regular basis.

> 65% reported that very minimal customization of the CDS tool was allowed across hospitals or practices.

> 68% stated that the organizational approach to alerts and CDS was a combination of “buy” and “build.”

> Among the value-added decision support initiatives that showed a return on investment (ROI), Sepsis and VTE ranked as the top two.

> Analytics for Radiology was the top area of CDS that was being considered by the respondents.

> 73% felt that ACR Appropriate Use Criteria were the most appropriate for radiology.

> 89% were not incorporating cognitive computing or artificial intelligence.

> 50% reported limited activity around consumer related data integration such as patient monitoring.

Discussion on the survey results pointed out the great variation in maturity in CDS system integration. Dr. Jerry Osheroff noted the CMS-recommended “CDS 5 Rights Framework” is a very helpful guide to shape CDS to drive performance and quality. The spectrum of maturity levels can be seen in each of the 5 CDS Rights dimensions. The challenge: “Make the RIGHT thing to do the easy thing to do!”

Dr. Michael Kramer noted that very few organizations assess all the 5 Rights during the development. Even less common is some form of evaluation to see if the rule continues to fire. In one example, a health system’s lab-test names changed but the rule was not updated. Important safety and quality outcomes can become unreliable without anyone knowing the system configuration has changed.

There was common support for a goal of finding non-interruptive methods in CDS. Alerts are a feature in the immature stage, whereas non-interruptive functionality would reflect the mature stage. Alerts can be seen as “guard rails,” designed to keep the user on track. However, they can eventually turn into “stop signs” that become interruptive and lead to “alert fatigue.” Dr. Pete Stetson of Memorial Sloan Kettering Cancer Center noted that alerts are a form of data displays, but the real need is cognitive support through visualization and summarization—“finding what you need when you need it.” Dr. Michael Kramer said, “Good design means that best practice is hardwired into the workflow and the alert only fires when someone deviates from that standard. Good alerts are designed in the context of streamlined workflow and rarely trigger.” Dr. David Classen added that CDS alerts should be viewed along a continuum—they initially educate on evidence-based medicine guidelines and over time they become guardrails as clinical knowledge becomes learned behavior.

The discussion evolved into identifying a “mature” model of CDS, and agreed that a standardized maturity model does not yet exist. Key elements in the maturity of CDS were listed as follows:

> Definitions

> Goals

> Internal Alignment/Buy-In

> Control/Management

> Alerts/Order Sets

> Process/Workflow—Future Vision

> Tools

> Accountability

> Performance Management

Dr. Osheroff offered an example of the mature CDS approach that makes the right thing easy as the Society of Hospital Medicine’s recommended/proven approach to improving VTE prophylaxis (a top priority target of SI organizations, per the Pre-Summit Survey). They recommend powerful order sets that incorporate simple VTE risk stratification (directly linked to corresponding risk-appropriate orders), as well as an easy mechanism to document contraindications to chemoprophylaxis via check box within the order set. This makes risk assessment and risk-appropriate ordering, as well as signaling exclusion from quality measures in appropriate circumstances, all a seamless part of the ordering workflow.

Dr. Michael Kramer noted that organizations may have hundreds of rules. Many of these rules predate any informatics standards and what are now recognized as best practices. It is common to have rules become ineffective or incorrect as codes change or processes change. Ownership through event analysis and decision-logic tracking and documentation are critical to keep the CDS timely, accurate and useful. In order to avoid an “interruptive” CDS, the process should be amended to evolve from alerts and redundancies to a system that delivers analytics and improves workflows. Yet, it was agreed, most systems are still in the interruptive phase of CDS. To advance to workflow applications the organization must embrace data as part of the clinical mindset rather than alert response. To do this, the organization requires layered teams of academics, clinicians and practical users creating decision strategies as a group. At Texas Health Resources, Dr. Luis Saldana formed the CDS Team to manage the lifecycle of CDS knowledge, e.g., order sets and alerts, and to measure the resulting demonstrable impact.

Drs. Alan Weiss, Nnaemeka Okafor and Anwar Sirajuddin summarized their learnings at Memorial Hermann by noting the following key points:

> Maturation of CDS requires support from the CEO, making it an organizational priority.

> To advance the application, you must recognize the problems through smart data analytics, identifying trends, spotlighting causes and explanations, finding options for solutions and using reports to change behavior.

> Strong analytics are needed to support improvements in both physician and patient outcomes.

Dr. Michelle Lauria from Eastern Maine concurred, noting that CDS supports consensus-building and alignment across clinical units, connecting specialties together, although establishing care guidelines across the full continuum is still in an early stage of development.

Additional supporting comments centered around the challenges in leading diverse groups to a CDS consensus, especially if alignment across the organization is lacking. Additionally, maturity levels may vary across clinical teams: some systems simply providing documentation templates (immature) to alerts (moderate maturity) and to efficient decision-support messaging systems (mature). An efficient decision-support messaging system should recognize that some care protocols require absolutes and some allow variations.

Dr. Kramer asserted that the CMIO/CHIO’s role should be to create visibility to such chaos and assign accountability to move forward to an improved quality focus both to legacy and new rules. CDS teams ensure there is a rigorous process to evaluate existing rules before adding more alerts to a system. The team should include subject-matter experts from the clinical side and the informatics side for coordination and elimination of chaos. Dr. Kramer offered questions to consider (see p. 5), stating that the safety and reliability of care processes are at-risk if the answer is no to any of the questions. Informatics teams should lead rigorous knowledge management and regular evaluation of clinical decision support and partner with clinical-evidence-based experts and process owners. “Expensive? Perhaps. Such expertise and rigor are the table stakes of managing our new models of hardwired and reliable systems of care,” he said.

The best strategy for an effective CDS system is Informatics + Analytics + Quality. Deployment for this strategic framework includes interdisciplinary management of the infrastructure, reduction of redundancies and alert fatigue and streamlining workflows through visualization to ensure predictive analytics that support clinical decision making.

The group acknowledged shared experiences and lessons learned from CDS implementation and management. Key concepts included issues related to the level of data required, the usability of the system, the need for monitoring, acknowledgement of organizational needs and acceptance of change. Fostering an environment where change is accepted and collaboration across organizations to create best practices are two key areas the group identified.

Future Visions

CDS is an IT-enabled tool that has changed the way care is delivered. Effective mature CDS contributes to improved clinical outcomes for the patient as well as improved performance measures for the physician and the healthcare organization. A mature CDS incorporates elements of actual clinical practice and the human equation. According to Dr. Nnaemeka Okafor, CDS evolution requires process engineering and accountability. Process engineering studies the workflow and collects and analyzes data, then relates the findings to the CDS toolbox. Accountability applies the appropriate resources, assigns training and monitors utilization and practice.

Dr. Jeff Sunshine said we should engage CDS to provide feedback on clinical choices that inform the physician, for example, of the percentage of clinicians who had previously selected each option or to offer predictive outcomes of the choices for that patient. Dr. Andy Spooner added, “Ideally you want the relevant knowledge presented at exactly the point a decision is about to be made—but how do you accurately predict that?”

An ideal future development would be the cross-system application of CDS so that one vendor system could “talk” to another vendor system across platforms. The reality is that patients cross systems and collaboration across platforms would contribute greatly to coordinated patient management. As Dr. Alan Weiss noted, “Cross-platform data integration does facilitate knowledge sharing, but the real challenge is leadership—holding people accountable for behavior change is key—how do we make that easy?”

Emergent Technologies

It was generally agreed that technological advances are only useful if they contribute to the organizational objective by providing valuable new options for getting the CDS 5 Rights correct through enhanced information, channels and formats. The current reliance on reports can lead to data overload without actionable strategies. If the purpose of reports is to change behavior then they need an appropriate display to create a culture of change. Retrospective reporting needs to change to real-time prospective predicting.

Some helpful technological advances could focus on the following:

> Natural language processing (NLP) and voice recognition to convert speech to text and trigger real-time relevant alerts, recognizing that speech creates a better patient story;

> Data mining to continually identify the most commonly used notes to simplify and standardize documentation;

> The Internet of Things, which represents an opportunity for real-time alerts based on data streaming;

> Patient, or consumer-generated data, inclusive of patent-reported outcomes, biometrics and notifications, allows patients to become part of the care team, which could be transformative, with tools such as Open Notes and Patient Portals that garner greater patient satisfaction;

> Patient-aggregated information, which can challenge privacy issues and result in external data in the record that is not vetted or validated, leading to new risks;

> Patient engagement outside of the encounter is a top priority for the organization, yet a real challenge to the provider, who must avoid the potential data tsunami of too much information.

Data overload was recognized as a real risk, with the related new technologies potentially becoming distractions from the real goal of improvements in clinical decision making. Dr. Thomas Moran said, “Technology is not the disrupter, we, the physicians need to be the disrupters!” The CMIO and CHIO must activate the catalyst for change. To do so, the CMIO and CHIO must have credibility, must have a seat at the C-Suite table and must relate actions to ROI.

What CMIOs/CHIOs Can Do to Prepare for MACRA and New Payment Models

MACRA will revise payment models by combining meaningful use and quality for the MIPS scale. The goal of CMS is a drop in resource utilization. In order to be prepared for MACRA the group agreed that certain strategies can be implemented in advance:

> Build MACRA provider planning and tracking capabilities to ensure a clear understanding of the annual MIPS or APM path that each provider will follow.

> Identify quality measures and build displays for those measures at the provider level even if using group reporting.

> Base performance assessment on Hierarchical Condition Coding (HCC) levels with Alternative Payment Model (APM) and Quality and Resource Use Report (QRUR) adjustments.

> Work toward a methodology to identify a true cost of care for specific services that will be bundled, such as total hips and knees for 2018.

> Identify clearly in advance decisions on shared payments per episode and reach those decisions via collaboration.

> Understand that risk adjustment, quality measures and payment may be dependent on documentation quality and accuracy, including the use of HCC codes and comprehensive problem lists. The care-planning process must include both medical and social problems to have the greatest impact. Risk-based APM’s may depend on managing non-medical problems.

Data Quality and Documentation Quality

Data quality and documentation quality are related but present different challenges. When performance measures drive compensation, the baseline data is critical and must be accurate. The care team relies on both clinical documentation and quality assessors in the EHR. Yet everyone agreed clinical documentation often is of poor quality, generally from cut-and-paste behaviors and redundancy. Dr. Stetson suggested the use of the Physician Documentation Quality Instrument (PDQI) as a simple means of assessing quality and providing feedback for improvement. Dr. Michelle Lauria suggested that physicians be required to do note-review on peers to identify issues and foster improvement. Dr. Jerry Osheroff described a new checklist tool to ensure that quality-measure data are accurate and trustworthy (recently published within a guide to improving care processes and outcomes). Dr. Alan Weiss said that part of the problem is the physician hasn’t defined data quality based on purpose—purpose related to influencing medical decision-making and clinical value.

Lessons Learned: How CMIOs/CHIOs can Advance CDS

1. Stress documentation reform to make records medically meaningful for the patient benefit. Change data documentation and collection from a reimbursement focus to a patient outcome focus.

2. Synthesize the experiences and strengths from the organizations within the Scottsdale Institute to identify what the future of CDS could look like.

3. Articulate the value proposition of the CDS Informatics Team to lead to role clarity and improved collaboration.

4.  Develop a maturity model for CDS levels, along with a recommended staging process and a corresponding benchmarking process facilitated by the Scottsdale Institute.

5. CMIO/CHIOs should take a critical role in translating health reform such as MACRA and other value-based contracting efforts into a value platform that leverages people/process/technology best practices.

6. Teach responsible clinical documentation skills and etiquette in medical schools as a requirement for delivering quality care.

7.  Apply pressure to vendors to standardize CDS tools and maintain CDS as a core function of the EHR. Knowledge management and analytics to ensure CDS reliability should be part of the standard EHR CDS package from vendors. Informatics teams should be able to easily report on alert fatigue and gaps in the annual review process with subject-matter experts.

8. Continue to expand CMIO/CHIO and Informatics resources and personnel in health systems, with senior-level decision-making, to realize the ROI on CDS.

9. Build a culture of innovation throughout the health system.

10. Build informatics capability that includes ongoing review and prudent development of CDS alerts. This process should include assessment and monitoring of CDS effectiveness against negative factors like alert fatigue.

 


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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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