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Enhancing Pediatric EHR Functionality: In North Carolina, One Organization Won’t Give Up

February 15, 2018
by Rajiv Leventhal
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EHRs for pediatric purposes “are not a whole lot different from paper charts,” says one deputy chief medical officer

Electronic health records (EHRs) are now commonplace in patient care organizations, but even today, several issues specific to children raise the risk that EHR usability can contribute to medical errors. Indeed, for the great majority of EHR systems in the marketplace, pediatric functionality has simply not been a priority, experts attest.

For instance, some folks note that EHRs’ ability to correctly track pediatric patients’ height, weight and other vital indicators is necessary to ensure that children are within normal ranges. But as the Pew Charitable Trusts and other healthcare organizations recently wrote in a letter to the Office of the National Coordinator for Health Information Technology (ONC), these functionalities in EHRs are very often geared toward adults.

For example, the letter stated, children’s weight affects the doses of medication received, which may differ from the dose typically administered to a fully-grown adult. EHR design may influence how clinicians order weight-based doses of medications, and could contribute to children receiving incorrect drug doses. In a well-known example, the weight-based dosing usability of an EHR contributed to a 16-year-old receiving 39 times the intended dose of a medication, they said. In the end, the letter urged National Coordinator for Health IT Don Rucker, M.D., “to consider and incorporate improvements to safety—especially for pediatric patients.”

But what is being done to correct what seems like such a critical health IT safety issue? About seven years ago, leaders from Raleigh-based Community Care of North Carolina (CCNC), a community network-based healthcare model organized and operated by practicing community physicians, received a federal grant under the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to evaluate the use of a Pediatric EHR Model Format to fill gaps existing across current EHR products and subsequently measure care quality outcomes. North Carolina was one of two states, along with Pennsylvania, that received funding to do a comprehensive evaluation of the format, which was developed by prominent healthcare systems such as Intermountain Healthcare, Duke Health and others, and which was commissioned by CMS (the Centers for Medicare & Medicaid Services) and AHRQ (the Agency for Healthcare Research and Quality).

It was around this time when Kern Eason, CCNC’s pediatric program manager joined the organization, specifically to develop and execute CCNC’s evaluation of the model format. Eason says, “At the time, I was getting a sense of the EHR landscape in North Carolina, examining if there were pediatric-specific systems being used in the area, and most importantly, thinking about the quality activities and metrics that CCNC is working on, either within the grant, or outside of it, and seeing if we can tie that to pediatric EHR functionality.”


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Essentially, Eason explains, the intent of what CMS wanted CCNC to do, under the CHIPRA grant, was to look at the model format as a driver or as having a potential role in quality improvement. “As adults, we represent ourselves when we go to the doctor, but children are always brought to the visit by a guardian. The system needs the capability to address issues like children of divorced parents in which the mother and father have different names. So how might you tie that back to the child’s record and [the provider] being able to access the information? You wouldn’t see these unique [issues] in an adult system,” says Eason.

Kern Eason

As such, CCNC project leaders, including Eason and Marian Earls, M.D., deputy chief medical officer, thought to look at these requirements through the lens of certain quality metrics—ones that were important to pediatrics such as developmental and behavioral screening. “So much of what pediatricians do is assessing that a child is developing adequately, making sure that the weight and height are [normal], and screening for autism and ADHD (Attention Deficit Hyperactivity Disorder). So we said, how can these requirements enhance the functionality of the EHR to deliver care that’s at that highest standard? That lens allowed us to approach the format in this way, it gave us leverage when talked to pediatric practices that partnered with us on this project, and it helped us do the evaluation from a user perspective,” Eason says.

In its approach, CCNC didn’t want to take just the words of the EHR vendors or the pediatric practices independently, but rather look at those in conjunction with each other and compare them. An example, Eason offers, would be when a vendor says that its system has the ability to do weight-based dosing. “So we said, how can we assess not only what the vendor has built to address the [adjustment of a prescription based on a child’s weight], but also the user’s experience and whether they are using the functionality or are even aware that the functionality exists in the EHR system?” Eason says.

At that time, when Eason was studying meaningful use requirements and around EHRs, and certification standards, he found that for pediatrics, there were only a handful of basic requirements, such as having a growth chart, which of course is ubiquitous to EHR systems used in pediatric systems today. “It was really basic. And even systems that were certified under that pediatric certification were so light in their ability to address complexities in pediatric healthcare,” he says.

What Was CCNC Able to Do?

When Dr. Earls first got started on this project, she assumed that once the requirements were reviewed, and when the grant expired, ONC would start to set mandates for EHR systems. But that’s not what happened, she attests. After CHIPRA ended, CMS gave the contract to research firm RTI International so it could take the results from both states’ evaluations—North Carolina and Pennsylvania. According to Earls, RTI distilled more than 500 requirements down to 46, which was then called the Children’s EHR Format 2015 Priority List.

From there, this past October, ONC called Earls to Washington, D.C. to share her expertise in the field. At that meeting was the American Academy of Pediatrics (AAP), an association which Earls said “was very interested and involved from the beginning,” and which worked with vendors on a national level to enhance their functionality. AAP recommended to ONC to begin with the pediatric EHR requirements in eight basic areas, which Earls says “are basic and don’t get deep into clinical content.” Earls adds that the stakeholders involved at that meeting had long discussions about next steps and about other requirements that may need to be added, but she notes that she doesn’t exactly know where things go from here.

Marian Earls, M.D.

Positively on the vendor front, many of the companies that CCNC worked with on this grant were willing to examine their systems, and potential gaps, without even being incentivized to do so, says Eason. “They wanted to do the right thing by their clients and make some adjustments along the way. Some enhancements were made by vendors that participated with us,” he says, offering Allscripts, eClinicalWorks and ReLi Med Solutions as three examples. To this end, two other vendors specific to the pediatric EHR space, Office Practicum and Physician’s Computer Company, participated out of curiosity to see how their systems stood up, says Eason. “But they also saw areas of opportunities to stay ahead of the path and enhance their functionality,” he adds.

Earls says that CCNC has also been working with AAP on developing vendor guidance, specifically around development and behavioral screening. In this area, still too often pediatricians are doing “incredible workarounds” or putting this content into the EHR manually. “It’s less than efficient but they have to address this need,” she says. “The vendor guide was intended to be put out there so people would incorporate this information in a way that was more useful for the practice, and also would be something that would provide structured data.”

Earls admits that it is frustrating when vendors say that a certain functionality is already the system, but in reality, it’s not structured data that can be pulled out for quality or population health management purposes. “That’s simply not what these [EHRs] are designed to do. To me, [the EHRs for pediatric purposes, as they exist] are not a whole lot different from paper charts—there is information you just can’t get out. You can get billing codes, but not what you need to do population health management,” Earls says.  

And on the pediatric practice front, one practice that Eason recently spoke with is still working closely with its vendor on making these enhancements. That practice, Eason notes, is using the 46-requirement set that RTI came up with as a basis of recognizing what’s most important. He contends that this requirement is something that is needed nationally and across systems right now. “A vendor can get caught up in a large influential practice client wanting a certain functionality or a new template, which might be more of a preference than a core functionality that supports quality pediatric care,” he says.

As it stands today, the CHIPRA grant has ended, and Eason says that alone is a challenge, since vendors “don’t have me calling them every other day asking them if they [were working on enhanced functionality].” He notes, “We are competing with so many other things that vendors are working on, so it’s a slow process and time is the biggest challenge. Some of these enhancements might not happen for several more years. But we need to keep this front and center and even though it hasn’t happened as fast as I would have liked, the work isn’t going away.”


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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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Survey: Half of Providers Use Multiple CDS Solutions, Use Varies by Provider

October 9, 2018
by Heather Landi, Associate Editor
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While three-fourths of providers currently use some sort of clinical decision support (CDS) solution, more than half are using multiple solutions, which indicates there is still not one solution that is meeting all of providers’ needs, according to a Reaction Data survey.

Reaction Data, a market research firm focused on the healthcare and life sciences industries, surveyed 180 healthcare physicians to gauge adoption of clinical decision support systems. Thirty-one percent of respondents hold the title of chief medical officer and 13 percent are chief medical information officers (CMIO) and another 13 percent are quality directors. The remaining respondents were chief nursing officers (CNOs), clinical informatics directors, health information management directors and IT directors. The majority of participants (91 percent) come from acute facilities with just 9 percent from ambulatory facilities.

The survey examines the main use cases for clinical decision support and the major vendors in the space, both as a full functioning system, and those who contribute to the early stages of a full CDS strategy. Three-fourths of respondents (74 percent) reported that they currently use a clinical decision support system.

On the clinical side, the number one use case for clinical decision support is medication orders, with 30 percent of respondents reporting CDS for this purpose, followed by lab orders (24 percent) and medical imaging orders (20 percent).

Cerner currently holds about 25 percent of the CDS market, according to the report. EPSi (Allscripts) has a 14 percent market share, Epic has an 11 percent market share and Stanson Health has six percent of the market. Many other vendors holding about five percent market share, including Nuance, Premier, Truven (IBM), Elsevier, Zynx Health and NDSC (Change).

These survey results on the clinical side of CDS indicate that the majority of people turn to their EHR vendor to provide the support they need. “After moving past the larger EHR providers in the market, you see companies like Stanson Health who offer a full CDS start to show up.

The report findings also illustrate that most vendors are in the early stages of their CDS strategy, as only 12 percent of the vendors listed by respondents offer a full CDS solution. About half of respondents offer an electronic health record (EHR) solution and 37 percent offer CDS as a secondary component.

Just slightly more than half (55 percent) of respondents said they currently use multiple solutions or components for their CDS needs rather than one system. For example, a provider might use one solution for aiding in drug ordering, and another solution for their clinical needs.

Of those currently using multiple solutions about half of that group said they plan to continue using multiple solutions moving forward, which indicates that there still is not one solution that meets all of respondents’ CDS needs. Looking at future plans, about a quarter of respondents plan to standardize on one platform and another quarter of respondents said they are unsure what their organization’s plans are.

“With only a 9 percent replacement rate everyone seems to be staying put for the most part. From our commentary, it appears clinicians are either satisfied with their current vendor, or are just holding out until they find a solution that meets all (or close to all) of their needs,” the report authors wrote.

The report authors also note there is room for growth in the clinical CDS market. “Things like real-time data mining in connection with decision support can improve clinicians’ views of the usefulness of the product. Others feel it’s helpful, but only for training purposes, the idea being that as time goes on you start to derive the same conclusions as your CDS solution,” the report authors wrote.

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