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CMIOs Parse the Complexities of Physicians' Dissatisfaction with EHRs

March 7, 2018
by Mark Hagland
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CMIOs analyzed the issue of physician dissatisfaction with EHRs—and what might be done to remedy it

What does the apparently widespread dissatisfaction of physicians in practice, with electronic health records (EHRs) mean for the eventual success or failure of EHRs, in the context of the essential need for them to succeed in patient care organizations? And what can—and should—medical informaticist leaders in those organizations be doing right now to change the narrative around MD EHR dissatisfaction?

Those questions were at the heart of the discussion during the course of the CMIO Roundtable, held Tuesday afternoon at HIMSS18 in Las Vegas. John Halamka, M.D., CIO of Boston’s Beth Israel Deaconess Medical Center, led a lively session that involved four brief presentations by panelists, and then a wide-ranging discussion, and audience question-and-answer session, in front of an audience that was overwhelmingly composed of clinical informaticists.

Halamka was joined by Michael I. Hodgkins, M.D., vice president and CMIO at the Chicago-based American Medical Association (AMA); Natalie M. Pageler, M.D., CMIO at Stanford (Calif.) Children’s Health; and Taylor Davis, vice president of innovation at the Orem, Ut.-based KLAS Research.


(l. to r.) Davis, Pageler, Hodgkins, Halamka, on panel

Hodgkins went first, and spoke about the broad national trends in the area of physician satisfaction/dissatisfaction with EHRs—and what needs to be done about that. “We didn’t have much control over the EMR,” Hodgkins said. “Remember 2008, when they we relooking for shovel-ready projects, and they decided that every EMR was a shovel-ready project? The current problem? We’ve all heard about burnout. And the AMA has been doing biopsies on burnout for years. In 2014, the number was 40 percent; in 2016, that number was already about 50 percent.”

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The implications of the reality of high percentages of EHR-embittered physicians are many, Hodgkins said.  “Burned-out physicians do a poor job; they create more patient safety problems,” he said. “A year ago, the AMA hosted ten of the CEOs of the leading integrated health systems, and they published a white paper, and declared burnout the most important health crisis of our time,” he noted. “Just to quantify it for you, the CEOs of these health systems basically said that a burned-out physician costs them between $500,000 and $750,000 a year. Think about that—in terms of replacement costs, lost productivity, etc. So, however you want to measure it, in terms of physicians leaving the field, or patient care issues, your organization needs to pay attention to this. And studies from the AMA and Mayo or the AMA and Dartmouth, studies have shown that for every hour that physicians spend on direct patient care, they spend two hours on documentation and administrative issues; and that doesn’t even include so-called ‘pajama time.’”

Hodgkins continued, “Between 2011 and 2014, somebody did the math and said there was a 1-percent loss of productivity as the result of EHR use; and that sounds very conservative, really. That’s the equivalent to the graduating class of seven medical schools during the same timeframe. Think about the loss of people leaving as a result of burnout. Think about that from a workforce perspective, and from a patient care perspective. And we have been struggling with this… There are now 200,000-plus or so health apps, and 320 mobile apps [emerging] every day, by some estimates. All this sets us up for a whole new wave of potential problems that can generate even more burnout among physicians, unless we address the issues early and quickly. 200,000-plus apps. There’s no FDA oversight of that space; it’s a Wild West. And those apps generate reams of new data.”

In that regard, Hodgkins said, “The AMA feels very strongly that physicians and clinicians need to be involved in the development of these apps. We did a survey in 2016 and found that in general, in spite of their experience with the EHR, 75 percent of physicians thought they could potentially benefit from this new crop of digital health solutions; they recognize that it’s hard to manage chronic health problems like hypertension, in the clinic.”

What Stanford Children’s Health is doing to improve MD EHR satisfaction

Despite all the challenges, the leaders of some patient care organizations are actively working to improve the situation. Dr. Pageler, the CMIO at Stanford Children’s Health, told the audience that she and her colleagues have been working hard to enhance physicians’ satisfaction with EHRs and with their work. Among their strategies: “We have a very extensive education and personalization program; we call it Home For Dinner,” she testified. “Three components were involved that allowed us to gather information about providers. We used our EMR’s data to obtain an efficiency profile” with regard to how efficiently physicians appeared to be documenting. “We did a survey to get their own perspective on what they’re doing with the EHR. And finally, we did observation sessions with individual physicians, with [help desk] trainers going out and observing physicians” doing their documentation. Those sessions clearly gave us a lot of information on what MDs were doing, but also on what we could do to improve workflows in the clinics.”

Following those steps, Pageler said, “From that information, each provider was given a personalized learning plan, complete with personalized tips, with special tools. The providers were incentivized by our organization to do this; they got funding for participating in the program. From the program we did see some significant improvement in education and decreased turnaround time.” Physicians motivated to set goals for themselves made “dramatic changes” in the amount of time they spent documenting. “For example,” she said, “one of our more experienced nephrologists, was spending a ton of time documenting on the weekends; his goal was to stop spending time on the weekends; and he’s achieved that.”

One key element in all this, she said, was that “CMIOs need to get involved at all levels, within medical specialties,” across patient care organizations, and nationally.

A fresh look at the landscape nationwide

KLAS Research’s Davis spent some minutes sharing information about surveys of CIOs and others, around this set of issues. “I am really, really nervous that the level of hope around EMR success is at an all-time low,” Davis said. “When you don’t have hope that you can be successful, you act in different ways, and it becomes a self-fulfilling prophecy. I was in a focus group with 14 CIOs. Everyone agreed that EMRs were key” to overall work satisfaction among practicing physicians. “I asked, who here agrees that you can get your physicians to be successful and even grateful for your EMR? One hand came up. That’s a problem. And let’s talk about the issues. There are documentation requirements; we’re turning physicians into clerks. But there are organizations that are highly successful with their EMRs, and their clinicians are satisfied with them.”

In that regard, Davis said, KLAS 15 months ago created something called the Arch Collaborative, to help the leaders of patient care organizations rethink EHR usability, and the satisfaction of physicians and other clinicians, with EHRs. One key insight? Physicians feel incompetent, stupid, when interacting with EHRs. Like Pageler, Davis told the audience that it is essential for healthcare IT leaders to help the physicians in their organizations personalize their EHRs, for greater usability. And, he added, “The most predictive factor of satisfaction is not which EMR you’re using, but your organization, based on culture. … We believe that the EMR magnifies culture, and issues within an organization,” he said. “But you can be successful.”

“At Beth Israel Deaconess,” Halamka noted, “we’ve created a program called Crowdsourcing. We have clinicians who code. And if you create an app specific to your area, go for it. We tell them, here are the rules of the road, and we do version control, and then we’ll put it into our approved app store. We have about a dozen apps in that store already—in orthopedics, cardiology, and so on, and all kinds of interesting emerging technologies. And it truly is pride of work, created by doctors and for doctors.”

And, Halamka added, speaking of the keynote address delivered Monday by Eric Schmidt, the former chairman of Google, in which Schmidt proposed that in the future, physicians will make use of virtual-assistant technology in their patient visits that will eliminate the need for the burdensome levels of documentation currently required, “Eric Schmidt stole my thunder” in this context. “The future of documentation,” he said, “should be, the doctor and patient have a discussion, with an ambient device recording key information, and what is included in documentation should be determined by the specialty societies.”

 

 


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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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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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KLAS Report: Behavioral Health EHR Vendors Demonstrate Poor Performance

October 10, 2018
by Heather Landi, Associate Editor
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The behavioral health electronic health record (EHR) vendor market has shown poor performance, to date, according to customers, who cite slow development, implementation challenges and lackluster customer support, according to a KLAS Research report.

A recent KLAS report examines behavioral health EHR performance, based on interviews with 149 unique organizations to get their perspective on the performance of these solutions. According to the organizations interviewed, the settings in which behavioral health EHRs are used are primarily outpatient/private practice (78 percent); intensive outpatient/residential day program (64 percent); inpatient residential treatment center (42 percent) and acute psychiatric services (22 percent).

The report, KLAS’ first on behavioral health EHRs, is intended to give executives at behavioral health organizations a high-level overview of the market and to shine a spotlight on where vendors can improve. Specifically, the report dives into the behavioral health vendors used most frequently (in both inpatient and outpatient settings) and their performance in product quality, development, and service and support. 

Organizations who offer behavioral health services need robust IT solutions that can support their efforts, however, on average, the overall performance of behavioral health vendors is very low. According to KLAS, the average overall score for behavioral health vendors is 70.8 (out of 100), putting behavior al health in the second percentile of all software market segments that KLAS measures (about 100 total).

Several factors contribute to this low performance, KLAS researchers note in the report. Organizations’ needs vary greatly based on the types of services they offer and the states they operate in, and this latter factor specifically impacts reporting. What’s more, a one-size-fits-all solution isn’t adequate for most organizations. Also, behavioral health vendors often overcommit on what they can deliver and are slow to develop the functionality organizations need and request.

According to KLAS “While vendor performance is low across the board, most frustrated customers plan to stay with their behavioral health vendor due to limited resources and a lack of compelling alternatives,” the researchers wrote.

Among the vendor solutions covered in the report are Cerner’s Community Behavioral Health solution, Cerner’s Millennium Behavioral Health, Core Solutions, Credible, Harris Healthcare, Netsmart, Qualifacts, Valant and Welligent.

Credible, a Rockville, Md.-based vendor that provides web-based EHR software for behavioral health providers, is leading what, so far, is an underperforming segment with wide variation, according to the report. KLAS researchers also note that Valant, a Seattle-based company that behavioral health HER software, is strong among private practices.

“Credible and Valant manage to give their customers a more consistent experience,” the report authors wrote. “Of the vendors used broadly in both outpatient and inpatient settings, Credible is most consistent thanks to their stronger implementation and training process, which has helped most customers find success with the easy-to-use, cloud-based system. Valant, whose customers are mostly private practices, also has an easy-to-use product, which was designed by a licensed psychiatrist. Valant’s multi-pronged approach to training (which includes a train-the-trainer program as well as online tools, such as webinars and blogs) helps private practices feel they get good value for their money.”

Despite the challenges, few are planning to replace, KLAS notes. One CIO interviewed for the report said, “Our CEO was considering other options a while ago. That person spends every spare minute trying to figure out what is best for us, and the CEO's research suggested that there really isn't anything better than [our current EHR] on the market.”

KLAS researchers also found that most behavioral health vendors have been slower to develop than customers would like or have failed to keep development promises. “Missed development timelines are referenced by almost all customers who say their vendor hasn’t kept promises,” the report authors wrote. “Even Credible, the overall top-performing behavioral health vendor, has overcommitted on timelines, specifically for new treatment-planning and state-reporting functionality.”

Cerner is the most mature of the enterprise health system EHR vendors when it comes to behavioral health, according to the report. Cerner has been developing their go-forward Millennium platform and incorporating learnings and content from their acquired Anasazi product (renamed Community Behavioral Health).

KLAS researchers found that overall customer satisfaction with the two products is comparable. In regard to Millennium, health system clients report higher satisfaction; relatively strong support and previously unattainable benefits, like integration across service lines, make up for product inadequacies mentioned by some behavioral health–specific Millennium customers.

Looking at other health system EHR vendors, Meditech has customers live with their integrated behavioral health solution, though adoption is light to date. Epic recently released a behavioral health–specific module, but no customers were yet live at the time of this research. Several of Epic’s inpatient EHR customers say they would have to pay an additional fee for the behavioral health module, according to the report.

Allscripts has no specific platform for behavioral health and recently sold their stake in Netsmart, making them the only EHR vendor—among those in use at large health systems—with no behavioral health–specific solution, the report authors state.

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