Despite Deadline Reprieve, Imaging Informatics Teams Feel Sense of Urgency About Clinical Decision Support | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Despite Deadline Reprieve, Imaging Informatics Teams Feel Sense of Urgency About Clinical Decision Support

January 31, 2018
by David Raths
| Reprints
‘The deadlines have changed, but the requirements have not’
Although implementation of a law to require clinical decision support (CDS) use involving diagnostic imaging orders was pushed back from 2018 to 2020, imaging informatics executives still feel pressure to accelerate efforts to deploy a CDS system and integrate it with their EHR.  
 
In 2014 Congress passed a law that will require referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services for Medicare patients. If the ordering provider does not consult AUC rules via clinical decision support before the order is placed, CMS will not pay the for the imaging. 
 
Much to the relief of imaging informatics executives, the effective date for the Protecting Access to Medicare Act (PAMA) has been pushed back from January 2018. 
 
In a recent Society for Imaging Informatics Management webinar, Kevin McEnery, M.D., a professor and director of innovation imaging informatics at University of Texas MD Anderson Cancer Center, explained that CMS would use the next year or so to upgrade its claims systems. Then 2020 will be an education and testing period, and the decision support penalties will kick in in 2021.
 
“For the people implementing systems, this timeline provides you the framework you need to align your project plans,” McEnery said. “You need to have CDS up and running by 2020 in order to take full advantage of the education and testing period. I would consider that an optimization period.” 
 
“The deadlines have changed, but the requirements have not,” McEnery said.  The extra time offers informatics leaders an opportunity to convince skeptical clinicians that this process can be beneficial to them, he added. “With providers, it is the extra clicks and alert fatigue that caused the primary pushback to the initial implementations of clinical decision support,” he said. Another issue is that clinicians using CDS can provide histories that are accurate for CDS but do not truly communicate to the radiologist the actual reason for the examination and the entirety of the patient’s clinical presentation.
 
As an aside, he mentioned that for those institutions that have implemented CDS or are close, it is worth 20 out of 40 points in the process improvement, category for MACRA, “so for those early adopters there is a benefit to continue to adopt.”
 
Speaking about early implementations, which he referred to as Version 1.0, McEnery said they involved putting a system in as an appendage to the EHR, and then having that system operate alongside the EHR but not integrated into it. “That is one of the reasons for some of the pushback from physicians. What you are seeing now is the idea that not only do you need to implement a CDS platform but you also need to look at ways to optimize your EHR to leverage that platform. By optimizing it, you could potentially have better acceptance by providers.”
 
With a January 2018 deadline, you would really have to put a Version 1.0 product in and your scope would have to be limited to achieve your goals, McEnery continued. “With the new deadline, you can look at your platform and optimize your EHR to fully leverage the capability of the platform for clinicians and radiologists.”
 
One imaging executive who has had considerable experience with implementing CDS is Keith Hentel, M.D., chief of the Division of Emergency/Musculoskeletal Radiology and executive vice chairman in the Department of Radiology at NewYork-Presbyterian Hospital-Weill Cornell Medical Center. 
 
During the webinar Hentel spoke about the urgency of planning for CDS implementation and some lessons learned from Cornell. “Everyone realizes that even though the program has been delayed, they need to be planning for it,” he said. 
 
Hentel said Cornell started working on CDS for imaging around 2005 when radiologists became targets for the reported increased utilization of imaging and the fear that this was going to break the Medicare program. “We thought CDS was a good idea — doing the best imaging at the right time,” he said. Cornell was selected to be part of the Brigham and Women’s convener group in a Medicare demonstration project, which was and is the largest demonstration project of clinical decision support for imaging ever done.  
 
That research didn’t show a huge impact on utilization or appropriateness of the imaging performed, he said. “One of the major contributing factors was that our work flow was very cumbersome. There was a lot of physician dissatisfaction in our enterprise when we turned on this system. In fact, we had initially thought that what was good for our Medicare patients was good for all our patients, so we did a very broad go-live, which eventually got pared back due to clinician complaints.” 
 
One of the reasons the Medicare imaging demonstration project may not have been as successful as it could, Hentel added, is that when you look at the interactions that took place, only a very small percent, less than 5 percent, were actionable alerts to the clinician or had any potential to improve care. “So this ended up with a lot of alert fatigue and physicians just ignoring what was on the screen, not to mention the fact that some of the nationally available appropriate use criteria conflicted with what we consider local best practice at Cornell,” he said. “That created a problem for some of our clinicians who didn’t quite know what to do. The final problem we saw was that there were no consequences of not using the CDS.”
 
When Cornell sought to do CDS again, it tried a different approach and mentality. “We went from a shotgun method to a very surgically precise method,” Hentel said. “What I mean by that is we didn't’ target CPT codes anymore. We targeted specific clinical presentations and specific imaging exams that we knew were ordered incorrectly.”
 
They also changed from a more global view, where they used nationally available appropriate use criteria, to what they considered local best practice. They also changed from strictly physician-entered orders to both clinician and automatic checks of AUC with information pulled from the EHR to lessen the burden on order providers. 
 
Cornell also more narrowly defined its goals. “Now every intervention we put in place, we have a well-defined goal, Hentel said.  “That goal may be decreasing inappropriate utilization; it may be making sure the ordering provider orders the most appropriate exam. We define a goal for every intervention and that has been very helpful.”
 
“With PAMA, we have had to retool again. We decided to put in our application to be a ‘provider-led entity’ and define our own AUC,” he added. “We are doing that now and it involves multiple physician groups. We have very complicated governance that involve subspecialty radiologists and physicians of all kinds that go over AUC and approve every implementation of a rule we put into our program.” 
 

The Health IT Summits gather 250+ healthcare leaders in cities across the U.S. to present important new insights, collaborate on ideas, and to have a little fun - Find a Summit Near You!


/article/ehr/despite-deadline-reprieve-imaging-informatics-teams-feel-sense-urgency-about-clinical
/article/ehr/uc-davis-health-s-physician-specific-approach-addressing-burnout

UC Davis Health’s Physician-Specific Approach to Addressing Burnout

October 16, 2018
by Rajiv Leventhal, Managing Editor
| Reprints
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].”

Webinar

How to Harness Your Hospital System Data via Advanced Content Management

For years, healthcare institutions have attempted to manage paper documents and electronically captured PDF files. These documents can be electronically stored in various databases like EHRs, ERPs...

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.

 


More From Healthcare Informatics

/news-item/ehr/report-athenahealth-has-multiple-bidders-sale-company

Report: athenahealth Has Multiple Bidders for Sale of the Company

October 15, 2018
by Heather Landi, Associate Editor
| Reprints

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.”

Related Insights For: EHR

/news-item/ehr/klas-report-behavioral-health-ehr-vendors-demonstrate-poor-performance

KLAS Report: Behavioral Health EHR Vendors Demonstrate Poor Performance

October 10, 2018
by Heather Landi, Associate Editor
| Reprints

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.

See more on EHR

betebettipobetngsbahis