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In Denver, Mining EHR Data for Public Health Monitoring, at a Very Local Level

March 9, 2017
by Heather Landi
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CHORDS collects, analyzes and presents data from participating partner EHRs into one registry per topic that can be used to monitor population health
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Public health officials are finding that, in many cities, there are significant health disparities and health gaps among neighborhoods, with childhood obesity rates and tobacco use much higher in some neighborhoods compared to others, which can contribute to different life expectancy rates. In the Denver metropolitan area, a collaborative pilot project is leveraging electronic health record (EHR) data to monitor public health trends and evaluate interventions, and the data service is providing public health officials with data to identify and address health disparities.

The Colorado Health Observation Regional Data Service (CHORDS), based in Denver, is a regional partnership between Colorado health providers, public health departments and the University of Colorado Denver to share health data in order to track population health trends and develop effective interventions. CHORDS, which is a pilot project by Denver Public Health, a part of Denver Health and Hospital Authority, collects, analyzes and presents data from participating partner EHRs into one registry per topic that can be used to monitor population health and conduct research.

Currently, there are 12 partner organizations that contribute data to CHORDS, including Children’s Hospital Colorado, Kaiser Permanente of Colorado, Denver Health and the Colorado Alliance for Health Equity and Practice, and a number of federally qualified health center (FQHC) organizations. Technology partners for the project include the Denver Public Health Department and the Colorado Clinical Translational Sciences Institute.

Each registry collects and presents health information specific to its topic area. For example, to monitor tobacco use, CHORDS collects demographic characteristics and geographic information on the patient and their visit, in addition to whether or not the patient uses or is exposed to tobacco. This information is extracted and used to populate the tobacco registry.

Public health officials in the Denver area are tapping into data from CHORDS to see the prevalence of health issues, such as childhood obesity or tobacco use, in the region, and can even map the variance down to specific neighborhoods. Officials can then take the data to city council representatives and community forums to open up discussions about health inequalities and disparities, according to Art Davidson, M.D., director of informatics and epidemiology at Denver Public Health and CHORDS project director.


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“Our goal,” Davidson says, “is to get politicians, policymakers, community-based organizations and community advocates interested in moving the agenda and moving the needle on public health issues.”

CHORDS, which refers to both the technology platform and a virtual organization of partners, currently has registries on obesity, tobacco use and exposure, diabetes, cardiovascular disease and depression. Examples of relevant data fields pulled from EHR data include, within the obesity registry, BMI, height and weight, and within diabetes, diabetes diagnosis codes and hemoglobin A1C lab test results. The 12 health entities in Colorado that are participating contribute data broken down by race, gender, age and location. Project leaders want to expand the data service to include registries on asthma, hepatitis C and congenital heart disease.

The use of EHR data for health monitoring is not unique, but applying these efforts at a local level is a relatively new concept, Davidson says. There are several national initiatives that have developed networks, including the Food and Drug Administration (FDA)-funded Sentinel Initiative and PCORI-funded PCORnet. Efforts to adapt these national models have been implemented locally through New York City’s Primary Care Information Project, and the MDPHnet program in Massachusetts.

According to Davidson, data sharing in the CHORDS health data network is powered by PopMedNet, a software application that enables the use of distributed data networks. The CHORDS instance of PopMedNet is hosted and supported by the University of Colorado Cancer Center’s Research Informatics Shared Resource with blended funding from National Institutes of Health (Colorado Clinical and Translational Sciences Institute) and a variety of grants from Colorado governmental and foundation funders.

Work to build CHORDS began about five years ago and project leaders first had to seek out healthcare provider partners to share their healthcare data and to make it available for public health agencies and researchers. The project leaders started with FQHC facilities and also reached out to other non-profit healthcare organizations. “It was somewhat challenging because we’re asking them to share health data for public use, so we had to make the case and build why this is important,” Davidson says. Each participating health care provider chooses which registry they want to participate in and contribute data to. As an example, a children's hospital would not provide data on adult indicators.

As CHORDS is a distributed database, data partners retain full control over their data and decide whether to answer a request for data. Each data-contributing partner, such as a hospital, stores data from their EHR in a virtual data warehouse (VDW). Each data-contributing partner requests and receives permission to download a PopMedNet “client” that connects their VDW datamart to the CHORDS network. CHORDS securely exchanges data using the client through a federated query, removing all personally identifiable information before data are shared.

Establishing robust, transparent governance policies and principles fostering data sharing was key to building CHORDS and continues to be critical to growing the health data network, Davidson says.

“You can have this technology down cold and you can fall on your face because you did not pay attention to the relational-issues and the need for a strong and transparent governance process that encourages and enforces trust,” he says.

CHORDS initially provided data to one local public health agency (Denver Public Health), but is expanding to include local public health users in the Denver metropolitan area, and other researchers across Colorado. The data service provides a way for public health officials and researchers to track population trends, across healthcare providers, and show the outcomes of policies and clinical- and community-based initiatives. Using data available in CHORDS, public health officials can monitor health indicators like community body mass index (BMI), community diagnosis and control of cholesterol and hypertension across populations.

As an example of how the information can be used, a public health agency can query for data on obesity rates and present to city council representatives in the form of a map showing obesity rates in a particular city council district and how it compares to other districts. “Public health officials can ask ‘Is there something you want to do as a policy maker to advocate for services in your neighborhood?’,” Davidson says. “And if you are the most obese neighborhood, they can look at, ‘Are you a food desert? Do you have bike lanes?’ Those are the kinds of social determinants of health that we try to bring out in this discussion. Community-based organizations can take that information and go to the politicians and policy makers and create a groundswell in the community with what they feel is evidence of health inequality and disparities.”

Davidson says researchers and public health officials are interested in the EHR data in the CHORDS health data network because EHR data can provide a level of accuracy, statistical power, and geographic detail unavailable through established health surveys, the traditional local public health information source, he says.

EHR data can answer many health questions that surveys or claims data typically cannot, he contends, pointing to the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS), a system of health-related telephone surveys that collect self-reported data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services. “If I want to know if you have hypertension, I can get that from the BRFSS, but if I want to know if your hypertension is controlled, I can’t get that from the health surveys, but I can get that from an actual measure of your blood pressure,” he says.

Davidson continues, “There is a lot of interest in the [EHR] data and how it can be used and how it could inform policy changes and system interventions. There are other people who look at it and are still skeptical, ‘Is it representative of the true population?’ This is still in its infancy, so we’re still learning about this. And that’s a major area of focus right now, doing some comparisons to the population-based surveys.”

In addition to contributing to public health monitoring efforts, Davidson says there are some other incentives for healthcare provider organizations to participate in the CHORDS project. According to Davidson, CHORDS population health monitoring is considered a specialized registry under Meaningful Use Stage 2, so eligible hospitals and providers in Denver County seeking MU Stage 2 incentive payments can fulfill the requirement to submit specialized registry data.



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Allscripts Sells its Netsmart Stake to GI Partners, TA Associates

December 10, 2018
by Rajiv Leventhal, Managing Editor
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Just a few months after Allscripts said it would be selling its majority stake in Netsmart, the health IT company announced today that private equity firm GI Partners, along with TA Associates, will be acquiring the stake held in Netsmart.

In 2016 Allscripts acquired Kansas City-based Netsmart for $950 million in a joint venture with middle-market private equity firm GI Partners, with Allscripts controlling 51 percent of the company. With that deal, Allscripts contributed its homecare business to Netsmart, in exchange for the largest ownership stake in the company which has now become the largest technology company exclusively dedicated to behavioral health, human services and post-acute care, officials have noted.

Now, this transaction represents an additional investment for GI Partners over its initial stake acquired in April 2016, and results in majority ownership of Netsmart by GI Partners.

According to reports, it is expected that this sale transaction will yield Allscripts net after-tax proceeds of approximately $525 million or approximately $3 per fully diluted share.

Founded 50 years ago, Netsmart is a provider of software and technology solutions designed especially for the health and human services and post-acute sectors, enabling mission-critical clinical and business processes including electronic health records (EHRs), population health, billing, analytics and health information exchange, its officials say.

According to the company’s executives, “Since GI Partners' investment in 2016, Netsmart has experienced considerable growth through product innovation and multiple strategic acquisitions. During this time, Netsmart launched myUnity, [a] multi-tenant SaaS platform serving the entire post-acute care continuum, and successfully completed strategic acquisitions in human services and post-acute care technology. Over the same period, Netsmart has added 150,000 users and over 5,000 organizations to its platform.”

On the 2018 Healthcare Informatics 100, a list of the top 100 health IT vendors in the U.S. by revenue, Allscripts ranked 10th with a self-reported health IT revenue of $1.8 billion. Netsmart, meanwhile, ranked 44th with a self-reported revenue of $319 million.

According to reports, Allscripts plans to use the net after-tax proceeds to repay long-term debt, invest in other growing areas of its business, and to opportunistically repurchase its outstanding common stock.

The transaction is expected to be completed this month.

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Study Links Stress from Using EHRs to Physician Burnout

December 7, 2018
by Heather Landi, Associate Editor
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More than a third of primary care physicians reported all three measures of EHR-related stress
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Physician burnout continues to be a significant issue in the healthcare and healthcare IT industries, and at the same time, electronic health records (EHRs) are consistently cited as a top burnout factor for physicians.

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.

Findings from a new study published this week in the Journal of the American Medical Informatics Association indicates that stress from using EHRs is associated with burnout, particularly for primary care doctors, such as pediatricians, family medicine physicians and general internists.

Common causes of EHR-related stress include too little time for documentation, time spent at home managing records and EHR user interfaces that are not intuitive to the physicians who use them, according to the study, based on responses from 4,200 practicing physicians.

“You don't want your doctor to be burned out or frustrated by the technology that stands between you and them,” Rebekah Gardner, M.D., an associate professor of medicine at Brown University's Warren Alpert Medical School, and lead author of the study, said in a statement. “In this paper, we show that EHR stress is associated with burnout, even after controlling for a lot of different demographic and practice characteristics. Quantitatively, physicians who have identified these stressors are more likely to be burned out than physicians who haven't."

The Rhode Island Department of Health surveys practicing physicians in Rhode Island every two years about how they use health information technology, as part of a legislative mandate to publicly report health care quality data. In 2017, the research team included questions about health information technology-related stress and specifically EHR-related stress.

Of the almost 4,200 practicing physicians in the state, 43 percent responded, and the respondents were representative of the overall population. Almost all of the doctors used EHRs (91 percent) and of these, 70 percent reported at least one measure of EHR-related stress.

Measures included agreeing that EHRs add to the frustration of their day, spending moderate to excessive amounts of time on EHRs while they were at home and reporting insufficient time for documentation while at work.

Many prior studies have looked into the factors that contribute to burnout in health care, Gardner said. Besides health information technology, these factors include chaotic work environments, productivity pressures, lack of autonomy and a misalignment between the doctors' values and the values they perceive the leaders of their organizations hold.

Prior research has shown that patients of burned-out physicians experience more errors and unnecessary tests, said Gardner, who also is a senior medical scientist at Healthcentric Advisors.

In this latest study, researchers found that doctors with insufficient time for documentation while at work had 2.8 times the odds of burnout symptoms compared to doctors without that pressure. The other two measures had roughly twice the odds of burnout symptoms.

The researchers also found that EHR-related stress is dependent on the physician's specialty.

More than a third of primary care physicians reported all three measures of EHR-related stress -- including general internists (39.5 percent), family medicine physicians (37 percent) and pediatricians (33.6 percent). Many dermatologists (36.4 percent) also reported all three measures of EHR-related stress.

On the other hand, less than 10 percent of anesthesiologists, radiologists and hospital medicine specialists reported all three measures of EHR-related stress.

While family medicine physicians (35.7 percent) and dermatologists (34.6 percent) reported the highest levels of burnout, in keeping with their high levels of EHR-related stress, hospital medicine specialists came in third at 30.8 percent. Gardner suspects that other factors, such as a chaotic work environment, contribute to their rates of burnout.

"To me, it's a signal to health care organizations that if they're going to 'fix' burnout, one solution is not going to work for all physicians in their organization," Gardner said. "They need to look at the physicians by specialty and make sure that if they are looking for a technology-related solution, then that's really the problem in their group."

However, for those doctors who do have a lot of EHR-related stress, health care administrators could work to streamline the documentation expectations or adopt policies where work-related email and EHR access is discouraged during vacation, Gardner said.

Making the user interface for EHRs more intuitive could address some stress, Gardner noted; however, when the research team analyzed the results by the three most common EHR systems in the state, none of them were associated with increased burnout.

Earlier research found that using medical scribes was associated with lower rates of burnout, but this study did not confirm that association. In the paper, the study authors suggest that perhaps medical scribes address the burden of documentation, but not other time-consuming EHR tasks such as inbox management.


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HHS Studying Modernization of Indian Health Services’ IT Platform

November 29, 2018
by David Raths, Contributing Editor
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Options include updating the Resource and Patient Management System technology stack or acquiring commercial solutions

With so much focus on the modernization of health IT systems at the Veteran’s Administration and Department of Defense, there has been less attention paid to decisions that have to be made about IT systems in the Indian Health Service. But now the HHS Office of the Chief Technology Officer has funded a one-year project to study IHS’ options.

The study will explore options for modernizing IHS’ solutions, either by updating the Resource and Patient Management System (RPMS) technology stack, acquiring commercial off-the-shelf (COTS) solutions, or a combination of the two. One of the people involved in the analysis is Theresa Cullen, M.D., M.S., associate director of global health informatics at the Regenstrief Institute. Perhaps no one has more experience or a better perspective on RPMS than Dr. Cullen, who served as the CIO for Indian Health Service and as the Chief Medical Information Officer for the Veterans Health Administration

During a webinar put on by the Open Source Electronic Health Record Alliance (OSEHERA), Dr. Cullen described the scope of the project. “The goal is to look at the current state of RPMS EHR and other components with an eye to modernization. Can it be modernized to meet the near term and future needs of communities served by IHS? We are engaged with tribally operated and urban sites. Whatever decisions or recommendations are made will include their voice.”

The size and complexity of the IHS highlights the importance of the technology decision. It provides direct and purchased care to American Indian and Alaska Native people (2.2 million lives) from 573 federally recognized tribes in 37 states. Its budget was $5.5 billion for fiscal 2018 appropriations, plus third-party collections of $1.02 billion at IHS sites in fiscal 2017. The IHS also faces considerable cost constraints, Dr. Cullen noted, adding that by comparison that the VA’s population is four times greater but its budget is 15 times greater.

RPMS, created in 1984, is in use at all of IHS’ federally operated facilities, as well as most tribally operated and urban Indian health programs. It has more than 100 components, including clinical, practice management and administrative applications.


Driving Success at Regional Health: Approaches and Challenges to Optimizing and Utilizing Real-Time Support

Regional Health knew providing leading EHR technology was not the only factor to be considered when looking to achieve successful adoption, clinician and patient satisfaction, and ultimately value...

About 20 to 30 percent of RPMS code originates in the VA’s VistA. Many VA applications (Laboratory, Pharmacy) have been extensively modified to meet IHS requirements. But Dr. Cullen mentioned that IHS has developed numerous applications independently of VA to address IHS-specific mission and business needs (child health, public/population health, revenue cycle).

Because the VA announced in 2017 it would sundown VistA and transition to Cerner, the assessment team is working under the assumption that the IHS has only about 10 years to figure out what it will do about the parts of RPMS that still derive from VistA. And RPMS, like VistA, resides in an architecture that is growing outdated.

The committee is setting up a community of practice to allow stakeholders to share technology needs, best practices and ways forward. One question is how to define modernization and how IHS can get there. The idea is to assess the potential for the existing capabilities developed for the needs of Indian country over the past few decades to be brought into a modern technology architecture. The technology assessment limited to RPMS, Dr. Cullen noted. “We are not looking at COTS [commercial off the shelf] products or open source. We are assessing the potential for existing capabilities to be brought into “a modern technology architecture.”

Part of the webinar involved asking attendees for their ideas for what a modernized technology stack for RPMS would look like, what development and transitional challenges could be expected, and any comparable efforts that could inform the work of the technical assessment team.




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