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EHR Configuration and Optimization: A Mayo Clinic MD Informaticist Shares Insights on the Journey

April 6, 2018
by Mark Hagland
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The Mayo Clinic’s Karl Poterack, M.D., shared insights on EHR configuration and optimization with HIT Summit attendees

Even the most renowned patient care organizations face challenges when it comes to process change. That was a key takeaway from the presentation made by Karl Poterack, M.D., medical director, applied clinical informatics, in the Office of Information & Knowledge Management at the Mayo Clinic health system. The Phoenix-based Dr. Poterack spoke on Thursday afternoon at the Health IT Summit in San Francisco, sponsored by Healthcare Informatics, under the headline, “Provider Spotlight: How the Mayo Clinic is Advancing Applied Clinical Informatics to Improve Patient Care.”

Speaking to an audience of healthcare and healthcare IT leaders at the Palace Hotel in downtown San Francisco, Dr. Poterack walked his audience through some of the recent clinical informatics history at the Mayo Clinic health system, which encompasses 20 hospitals in five states, as well as 2,900 staffed beds, 130,000 annual hospital admissions, and 1.3 million annual clinic visits, 66,484 employees, 4,590 physicians and scientists, 2,434 residents, fellows and medical students, 59,460 allied health professionals, and a portfolio of $11-12 billion in gross revenue. He himself works out of the Phoenix region of the organization.

Poterack shared Mayo’s experiences around the process of unifying is electronic health record (EHR). As he noted, “We had three different EHRs across those 20 hospitals; in Rochester, we had an amalgamation of a bunch of different systems. The primary one was vended, while there were a number of home-built systems. To an extent, each EHR was attuned to different individual practices or regions,” he added.

“Why change? A strategic decision was made,” Dr. Poterack told his audience, “to converge workflows, order sets, onto best practices. For years, Mayo had operated a bit like a holding company, with regional groups. Florida had evolved to do things Florida’s way, Arizona to do things Arizona’s way, etc., etc., and there was a recognition that perhaps we could develop [more universal] best practices, and that, when patients with the same symptoms and issues come to different facilities, they should get the same care. So the decision was made to converge on best practices. And so converging on the same EHR, with the same order sets, the same build, was seen as a way to build convergence. And there was some time pressure, because the vendor support for the key vended system in Rochester was going to end. So we realized that this was a good time to get onto the same system.”

Karl Poterack, M.D.


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Given that background situation, Poterack said, “We decided to undertake what’s been named the Plummer Project, after Henry Plummer, one of the six original physicians who established the Mayo Clinic. It was Dr. Plummer who really invented what we think of as the patient-centered record. At the time he did so, medical records were facility-focused, and entered into ledger books. There was no patient record centered on the patient; the record was centered on the clinic; and he basically flipped that. So because of his standing, we named our project of unifying our EHRs after him.”

That said, Poterack continued to say that, “Obviously, there were barriers we had to face. We’re a very distributed practice, with 20 hospitals in five states. We’ve got multiple stakeholders: neurosurgeons in Rochester, neurosurgeons in Jacksonville, anesthesiologists in Arizona, anesthesiologists in Eau Claire, and so on and so forth. And every doctor thinks he knows the best way to do things, and also that he’s in charge. So getting everybody on the same page and to converge on best practices, was a challenge.”

What’s more, Poterack said, “Cultural differences were a problem. Variations in practices were allowed, and that was cultural. And culture is influenced by geography.” Another major obstacle? “The ‘we can’t possibly change the way we do things’ argument. There can also be legitimate issues around resource differences.”

Process issues: past and present

One advantage that he and his colleagues had in making this change, Poterack said, is that the Mayo Clinic has a robust committee structure and a long-term track record for how to initiate changes. “We had a process for change, on which to build. What was our process? Essentially, it was to get together and talk about things. I will put our committee structure up against the structure of any organization.” And that, he said, has been a real strength.

In addition, Poterack said, “One of the things we’ve tried to bring into the discussion is informatics core content. There really is a science behind some of these things, there really are best practices. There’s core content to medical informatics; after all, it’s now a boarded medical specialty.”

Still, many things had to be worked out, and process had to be pursued in an organized, systemic way. For example, he noted, “One could ask the question, how many records can one user be allowed to open at one time? And a loud voice could say, ‘We should be able to have as many open as we want!’ But the reality is that there are actually published guidelines around this, there’s published evidence. So I’ve tried to regularly remind people that there is [a literature with evidence] behind this, that it’s not just all whim. And that’s true of many things, for example, good graphic design, which plays into this. There’s a science around how you lay out a screen, what you put on it, etc. And a lot of people are demanding things.”

With regard to timelines, the plan for the creation of a unified EHR was created in January 2015. Then, Mayo Clinic health system in Wisconsin went live in July 2017, followed by Mayo Clinic health system in Minnesota in November 2017, with Mayo Clinic health system in Arizona scheduled to go live in October of this year.

“What have we learned?” Poterack asked. “That you really have to identify the stakeholders. Who are the people who really have the authority to identify and make changes? You need people who know what the process actually is” around specific elements of physician and clinician workflow. “Department chairs may not know what the workflow really is, what the process on the ground looks like. Then, you need people who are going to be able to help effect the change, people who can help roll it out in their area and get people on board. It might be the people ‘in authority’; or it might be more informal persuaders. And then you really have to get them all in a room. Out of necessity, we do a lot of teleconferences and videoconferences, but there’s no real substitute for getting everyone in a room, physically, and saying, OK, we have a patient who comes into the ED, what’s our process, and what’s the best practice? And then you’ve got to be careful of the ‘loudest voice in the room,’ the person who’s louder and more forceful than others, or who does the largest number of procedures. They may or may not have the right way of doing something.”

In addition, Poterack said, “You need a set of principles for saying ‘no.’ And you need to keep ‘eyes on the prize,’ to keep the end goals in sight.”

Also, “You’ve got to be aware of the amount of time it will take” to plan and implement such a major change. “You also need people with expertise. And, when it comes to EHRs, you need help physicians and clinicians train to use the system, and to personalize it correctly for themselves. The reality is that EHRs are still not intuitive. Perhaps they will be someday. Remember what Adobe Photoshop was like years ago? You had to take a course in it and be trained; you couldn’t just pick it up and use it. Now, the programs on smartphones are so intuitive that 14-year-olds can just pick up a phone, take a picture, and do a better job editing that photo in the phone, than professionals did with Photoshop years ago.”

Finally, Poterack said, “The truth is about the ‘secret sauce’ to this is that there is no secret sauce.” Instead, he said, “You need to have appropriate expectations, and you need to know how to sometimes say ‘no’ to doctors.” In summary, he said, “Know your goals; get the right people involved; set the right expectations; and utilize the best practices, informatics expertise,” and so on. And keep moving forward with “eyes on the prize.”


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EHR Usability Issues Impact Pediatric Patient Safety, Research Finds

November 13, 2018
by Rajiv Leventhal, Managing Editor
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In an analysis of 9,000 pediatric patient safety reports from three healthcare organizations, researchers found that 36 percent of the reports were related to EHR (electronic health record) usability issues.

The research, published in the November issue of Health Affairs, and led by Raj Ratwani, Ph.D., director of the National Center for Human Factors in Healthcare, Washington, D.C.-based MedStar Health, and others, aimed to further understand the specific issues around why pediatric populations are uniquely vulnerable to the usability and safety challenges of EHRs particularly those related to medication.

To understand specific usability issues and medication errors in the care of children, the researchers analyzed 9,000 patient safety reports, over a five-year span, from three different healthcare institutions—two stand-alone pediatric institutions and one adult and pediatric institution that used Epic and Cerner EHRs (two institutions used Epic, and one used Cerner)—that were likely related to EHR use.

Of the 9,000 reports, 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm, the researchers found.

“The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing,” the research revealed.

The researchers noted in the study that pediatric patients are uniquely vulnerable to EHR usability and safety challenges because of different physical characteristics, developmental issues, and dependence on parents and other care providers to prevent medical errors. For example, they offered, lower body weight and less developed immune systems make pediatric patients less able to tolerate even small errors in medication dosing or delays in care that could be a result of EHR usability and safety issues.

Although the Office of the National Coordinator for Health Information Technology (ONC) has policies to promote usability—such as requiring system developers to incorporate feedback from clinicians into software design and development and mandating the testing of twelve high-risk EHR functions that are primarily related to medication—the researchers noted that these policies have not made a distinction between adult and pediatric populations. However, the 21st Century Cures Act of 2016 requires ONC to establish new voluntary criteria unique to EHRs used in the care of children.

For this research, the 9,000 reports—3,000 from each site—were reviewed to verify whether the events were related to the EHR and medication; determine whether EHR usability contributed to the event and, if it did, identify what the specific usability challenge was; identify the type of medication error; and identify whether the event reached the patient.

Of the 9,000 patient safety event reports that were collected, 56 percent were confirmed as being related to both the EHR and medication. Of these 64 percent had a usability issue as a contributing factor to the safety event, which amounts to 36 percent of the total 9,000 reports analyzed.

Of the 3,243 reports (36 percent) that had usability as a contributing factor, 19 percent reached the patient. Of these, 33 percent did not cause harm and did not require monitoring, 18 percent required monitoring or an intervention to prevent harm, 3 percent resulted in temporary harm, and the consequence was unknown for 46 percent, the researchers revealed.

One example of a usability issue that caused some harm was when a when a physician ordered five times the recommended dose of a medication without receiving an alert from the EHR, although the prescribed dose was outside the recommended range. Both vendor design and development, as well as implementation and customization, may be contributing to the challenges associated with system feedback, the researchers stated.

“To address this systemic problem, vendors and providers should consider developing more comprehensive design guidelines and use generalizable tools to assess usability and safety. The Leapfrog [computerized provider order entry simulation] tool, which assesses clinical decision support functionality, is one example of the types of tools that could improve the safety of implemented EHR products,” they said.

The researchers concluded, “To better prevent usability-related medical errors, the ONC could include safety as part of the voluntary certification criteria of EHRs for use with children and implement usability-related measures to assess EHR performance. Vendors and providers should use rigorous test-case scenarios based on realistic clinician tasks. Finally, the Joint Commission should assess EHR safety as part of its hospital accreditation program. The implementation of approaches such as these is needed to reduce patient harm related to EHR use.”

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Veritas Capital, Elliott Management Acquire athenahealth in $5.7B Deal

November 12, 2018
by Heather Landi, Associate Editor
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Private equity firm Veritas Capital and hedge fund Elliott Management will acquire athenahealth, the Watertown, Massachusetts-based electronic health record (EHR) and practice management vendor, for $5.7 billion, according to an announcement released Monday.

Veritas and Evergreen Coast Capital, a subsidiary of Elliott Management, will pay $135 per share for the health IT company, which represents a premium of approximately 12 percent over the company's closing stock price on Friday. The deal also represents a premium of approximately 27 percent over the company's closing stock price on May 17, 2017, the day prior to Elliott Management Corporation's announcement that it had acquired an approximate 9 percent interest in the company.

The deal concludes a six-month acquisition process and a tumultuous period for athenahealth and its leadership. Elliott Management, the sometimes-activist fund run by billionaire Paul Singer, has put pressure on athenahealth leadership to take the company private or explore a sale since the hedge fund acquired a 9-percent stake in the company in 2017.

Following the deal’s closing, Veritas and Evergreen expect to combine athenahealth with Virence Health, the GE Healthcare value-based care assets that Veritas acquired earlier this year. The combined business is expected to be a leading, privately-held healthcare information technology company with an extensive national provider network of customers and world-class products and solutions to help them thrive in an increasingly complex environment, the companies said in a press release.


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“After a thorough strategic review process, we have decided to enter this agreement with Veritas, which we believe maximizes value for our shareholders and accelerates our goal to transform healthcare," Jeff Immelt, executive chairman of athenahealth, said in a statement. Immelt was appointed to that position after company founder and CEO Jonathan Bush stepped down back in June. “Combining with Virence will create new opportunities for collaboration and growth. Operating as a private company with Veritas's ownership and support will provide athenahealth with increased flexibility to achieve our purpose of unleashing our collective potential to transform healthcare.”

This past 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 transaction is expected to close in the first quarter of 2019, subject to the approval of the holders of a majority of athenahealth's outstanding shares and the satisfaction of customary closing conditions and regulatory approvals. The athenahealth Board of Directors has unanimously approved the merger agreement and intends to recommend that athenahealth shareholders vote in favor of it at a Special Meeting of Stockholder.

The combined company is expected to operate under the athenahealth brand and be headquartered in Watertown, Massachusetts. The company will be led by Virence chairman and CEO Bob Segert and an executive leadership team comprised of executives from both companies. Following the completion of the transaction, Virence's workforce management business will become a separate Veritas portfolio company under the API Healthcare brand.

Athenahealth got its start in the health IT space as a developer of practice management systems for physician practices and has steadily expanded its suite of network-enabled services for revenue cycle management and medical billing, electronic health record (EHR) systems, patient engagement, care coordination, and population health services. The company ranked at No. 13 on the Healthcare Informatics 100 list for 2018, with $1.2 billion in revenue.

For the past 20 years, the company’s culture was driven by its outspoken CEO, Bush, and many athenahealth customers have said they like the strong culture and the company’s service business. It remains to be seen how this deal with impact new and existing customers.

In an interview back in June, Erik Bermudez, senior research director at Orem, Utah-based KLAS Research, said he had spoken with a number of key athenahealth customers about the potential for new management. “What I heard is, because of athenahealth being who they are and because of the strong culture that they have built, they are less worried about athenahealth than they would be if it were another company. And, they indicated that it might be a good thing.”

He continued, “It’s been a public company and it’s really hard to serve two masters, Wall Street and customers and other stakeholders. Customers I talked to indicated that a sale would bring in new ownership and perhaps bring in a different set of priorities, and that could really help athenahealth get back to their roots and back to the culture they had when they began. I think there’s still a lot of excitement, and there’s some hesitancy as well.”

In Monday’s announcement about the deal, Ramzi Musallam, CEO and managing partner of Veritas Capital said in a statement, “athenahealth is a market leader and a natural and strategic fit with Virence. Virence and athenahealth have differentiated and complementary solutions, deep relationships with their respective customer bases and a shared culture of commitment to innovation. We look forward to leveraging our expertise in the sector, as well as the capabilities and solutions across both companies to provide superior value to customers, and create exciting growth opportunities for both sets of employees as Bob and the team build the future of healthcare IT.”

Veritas, a government and technology focused investor, has been adding health IT companies to its portfolio in the past few years. The investor bought Truven Health Analytics from Thomson Reuters for $1.25 billion in 2012 and then sold Truven to IBM Watson for $2.6 billion in 2016. Veritas acquired the healthcare business (now known as Verscend Technologies) from Verisk Analytics for $820 million, in 2016. The investment then bought GE Healthcare’s value-based care division for $1 billion in April 2018, followed a few months later, in June, with Veritas-backed Verscend Technologies buying Cotiviti, a provider of payment accuracy and analytics driven solutions, for $4.82 billion.

Bob Segert, chairman and CEO of Virence, said in a statement about the athenahealth deal: “We are excited by the opportunity to partner with athenahealth, one of the largest and most connected provider networks in the nation, to drive outcomes that matter the most to our customers. athenahealth and Virence have complementary portfolios and highly-talented people, and this combination expands our depth and reach across the continuum of care. I'm looking forward to combining our mission-driven cultures to create an even stronger healthcare IT company.”

Elliott Management Partner Jesse Cohn said, “We are pleased to support this transformative transaction combining athenahealth and Virence, which we believe represents an outstanding, value-maximizing outcome for athenahealth shareholders.”

 Upon completion of the transaction, Elliott's private equity subsidiary, Evergreen Coast Capital, will retain a minority investment stake in the combined company. Evergreen Managing Director Isaac Kim said, “We look forward to taking part in this unique opportunity. Under Bob's leadership and with Veritas' strategic oversight and strong track record of value creation, we believe the combined company will be a true leader in healthcare IT, ideally positioned to improve outcomes and reduce the cost of care.


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Seven Best Practices for Optimizing EHRs Clinically and Financially

November 7, 2018
by Dan O’Connor and Joncé Smith, Industry Voices, Stoltenberg Consulting, Inc.
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You can make the most of your EHR system with these seven tips for two-pronged optimization

Healthcare professionals today face numerous competing daily tasks beyond patient care appointments. With the constant strain, healthcare facilities struggle with knowing if they are using their electronic health records (EHRs) to the full potential. To alleviate the confusion and optimize your EHR for combined clinical decision making and operational effectiveness, use the following seven tips.

Clinical Optimization Tasks

End-user education, data collection and system usability are the main areas of focus when initially assessing your EHR from a clinical standpoint. Are you collecting the correct information in the appropriate form? Are workflows efficient? Do clinicians have the appropriate tools, and are they using the EHR effectively? These questions can help as you conduct a comprehensive assessment, reviewing your EHR system and processes from patient registration to final billing.

  1. Conduct clinical end-user interviews– Begin by reviewing daily end-user operations. Ask employees what they think needs to be improved and what is working well. Then assess end users’ system utilization. Is user knowledge an issue? How often is end-user education provided, and does it align with system upgrades or application transitions? Do new hire EHR education modules include simple and clear documentation and real practice examples? One easy way to improve system knowledge is to partner new employees with an EHR superuser mentor to help them quickly become comfortable with system use. Having a good understanding of providers’ perception of how the system is functioning is a good starting point prior to looking at the specifics of system use, workflows, information storage and providers’ direct interactions with the system.
  1. Assess data collection processes– How information is collected impacts everything from direct patient care decision making to triggering clinical care best practice alerts appropriately. Can you trend information for research? Are you able to run historical reports based on cohorts of patient or diseases? These are just a few questions to consider when determining how data is collected, how it is stored and what data is being pulled from previous patient visits. Ensuring that the correct data is collected in the correct form is important, but making sure the workflow facilitates the provider’s view of aggregating data is just as critical. This is directly related to observing providers interacting with the system.
  1. Perform a usability study– Review how clinicians interact with the EHR including the hardware and clinical tools that correlate. Are providers documenting at the bedside, or are they using scribes? Do they effectively navigate the system? Do they document in real time or after patient contact? Evaluate how these observations line up with the initial end-user interview process. Are there gaps or discrepancies? Are there bottlenecks in the workflows or limitations due to equipment or space? These critical factors can significantly impact system usability. For clinical optimization post assessment, look for documentation points where data should be changed from either discrete to free form or free form to discrete. Work this into clinical workflows to alleviate end-user system frustration.

Financial Optimization Tasks

With clinical optimization assessment considerations in hand, concurrently look at revenue cycle management (RCM) concerns. Provider practices typically have limited staff fulfilling business office duties, with most juggling multiple hats. Bottom line: financial representatives must utilize more efficient workflows. Follow these financial optimization steps to save staff time and improve their ability to create clean claims and reduce denials.

  1. Create a list of authorization numbers per major health plan–Request a list of procedures that require authorization numbers from your payer representatives. During the appointment booking process, flag those procedures to prompt staff to call the payer for an authorization number and create a report to list those without one during nightly processing. Within the final financial clearance process, establish a step to check for an authorization number. If the A/R follow-up sees a new denial for a procedure not listed, it can easily be added to the list. By reviewing for the presence of an authorization number, you can minimize preventable denials.
  1. Ensure consistent copay collection– Health systems with multiple clinic locations often experience inconsistent copay collections over time. To regain lost traction, create quick reference sheets with standardized documentation of proper copay workflow, noting particular transaction codes for correct system postings. Make sure you participate in and assess monthly reports on the rate of copay collection per clinic location. Such reports hold each clinic accountable by direct comparison to peers and national benchmarks for copay collection, which is 98 percent of all scheduled appointments.
  2. Evaluate common claim denials– Do a deep data dive on your top 10 denial codes and identify the payer for each. Identify the root causes of each denial and correct faulty processes or overlooked administrative or business office steps. If poor coding is a root cause, provide additional education for providers. If procedure authorization is not routinely obtained, business office staff may need additional training on payer requirements.
  3. Reduce charge entry lag time– Using data from the EHR, create a weekly report with the following fields:
  • Patient ID– system’s unique patient identifier
  • Encounter number– system’s number for a specific care episode
  • Encounter start date– the date of admission for an inpatient care episode or the date of the visit for an outpatient care episode
  • Charge entry date– the actual date the charge was successfully posted (may not equal the charge entry date due to edits)
  • Service or procedure date of service– the date the procedure or service was rendered to the patient
  • Service department– the name of the ancillary department that performed the service/procedure

From this data set, calculate the lag time between the date of service for the procedure/service and the charge entry date. Sort by service department and calculate the range and average per department. Then, meet with the appropriate representative of the service department to discuss any entries that exceed five days. Ensuring departmental charges are posted within five days of the service greatly decreases the risk of lost charge revenue.

You can make the most of your EHR system with these seven tips for two-pronged optimization. Over time as technology evolves, it’s important to approach EHR optimization as a continuous process improvement effort. Keeping an open line of communication with key stakeholders and superusers across both clinical and financial areas, revisiting implemented changes to evaluate their effectiveness, and making data-driven adjustments throughout the process will help your organization get the most from your EHR investment.

Dan O’Connor, vice president of client relations, Stoltenberg Consulting, Inc.

Joncé Smith, vice president of revenue cycle management, Stoltenberg Consulting, Inc.

Both can be contacted at

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