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European CIOs Share Successes and Challenges around Moving into the New Healthcare

November 22, 2016
by Mark Hagland
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At WoHIT 2016, healthcare IT leaders from across Europe shared diverse stories of initiatives

It could almost as easily have been in Boston, Bismarck, Billings or Berkeley, as Barcelona, for all that was being said. But it was Barcelona on Monday, and it was at the World of HIT 2016 (WoHIT2016) conference, sponsored by HIMSS Europe (a division of the Chicago-based Healthcare Information and Management Systems Society), being held at the Centre de Convenciones Internacional de Barcelona (CCIB), in Barcelona, Spain.

With about 1,000 attendees from across Europe and beyond, gathered to discuss important healthcare IT and healthcare industry topics, two sessions—“The CIO as Whole Systems Leader,” and “The CIO as Regional Leader”—were among those that put particular emphasis on the challenges and opportunities facing CIOs of both health systems, and of regional and national healthcare organizations, as they work to transform care delivery and community health across Europe.

So on Nov. 21, in the session entitled “The CIO as Whole Systems leader,” Olivier Boussekey, M.D., CIO of the Groupe Hospitalier Paris St. Joseph in Paris, France; Antonio Fumagalli, CIO of ASST Papa Giovanni XXIII in Bergamo, Italy; and Philippe Kolh, M.D., CIO of the Centre Hospitalier Universitaire de Liège (University Hospital of Liege), in Belgium, described their current strategies and operational intiatives at their hospital based organizations. Meanwhile, in the session immediately following that one, “The CIO as Regional Leader,” two individuals who are leaders of much bigger organizations spoke about regional and national healthcare IT leadership—Juan Lucas Retamar Gentil, CIO of the Sistema Sanitario Público y de Bienestar Social de Andalucía (Andalusian Health Service), a regional health authority that encompasses one of the largest regions of Spain, and Seamus MacSuibhne, chief clinical information officer and head of the Council of Clinical Information Officers, of eHealth Ireland, a national eHealth initiative for Ireland, spoke of their work on a broader scale.

Making it all patient-centric

What all three CIOs in the first session agreed on was this: moving forward strategically means putting the patient at the center. As Boussekey of St. Joseph Hospital in Paris said, “For us, creating a paperless record was about the patient. Medical information needed to be available for all professionals everywhere and in real time, and massively shared. And We also had to maintain and prepare for compliance with all regulatory changes in France. And,” he quickly added, “always with a patient focus. Our vision was that we needed to deploy something that was a win for the hospital, a win for the clinicians, and win for the patient. We started by digitizing 8 million pages; we extended the usage of the EMR to everyone, and we connected all the different devices, to avoid paper everywhere in the hospital.”


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And “patient-centric” often means rigorous moves forward around clinician processes. For example, Boussekey noted, “All physicians are using voice recognition now; we no longer have secretaries to do any dictation.” Again, the focus here was patient-centric, in the sense that, given limited financial resources, it became clear to Boussekey and his colleagues that the cost of dictation simply had to be eliminated. “So how did we make this project successful? We deployed a strategy as a common project shared and built with all the physicians and nurses in the hospital,” he said. “We also really tried to explain tool usage—that all the tools being put in place were to add value. And of course, we’ve supported not only the project itself, but also the usage. I am using voice recognition every day as a physician,” he added. “I’d like to be able to share with fellow physicians, and when they complain that something doesn’t work, it’s important for me to be able to empathize and share that I understand.” Specifically in that case, Boussekey and his colleagues were able to help the hospital system to reduce staff by 30 FTEs’ worth of secretaries, while ensuring immediacy of data availability. What’s more, they also advanced the hospital towards a goal that is linked to a national mandate in France. “There is a nationwide objective in France to get 80 percent of discharge summaries to physicians on the day of discharge. Our hospital started out at 35 percent, but has been able to reach a level of 70 percent,” through the elimination of dictation.

In the region centered around Bergamo in northern Italy, Antonio Fumagalli has advanced his organization forward on several fronts in the past few years, again, with a strategic focus on patients. Among other things, his organization transitioned from an older facility into a completely new one, and went through that entire transition. What had formerly been the Odspedale Riunti became, in 2012, the Ospedale Papa Giovanni XXIII (named after Pope John the 23rd); the organization is a 1,000-bed public hospital, with 35,000 inpatient admissions a year, 3.75 million outpatient visits, and over 37,000 surgeries a year, along with some of the highest surgical and ICU volumes in the country. The organization moved into its new facility in 2015.

In Italy, as in France, the economics of care delivery and care management have played an important part in the strategizing forward around clinical IT. In particular, Fumagalli noted, the Bergamo region has been required by provincial authorities to streamline services and processes, with a mandate for more fully integrating services across the care continuum in the region. Among other things, the health system had to integrate a range of services, including a legal medicine center (judicial collaboration on violence and abuse), an addiction center, a family counseling center, and a regional vaccination service—all had to be integrated into a single, very broad umbrella of services.

As Fumagalli noted, the demands being made on his organization, as an integrated health system that increasingly is being transformed into a regional umbrella patient care organization, demand that CIO leadership extended into change management and change leadership, with a strong focus on optimally using resources to create the best possible delivery of care to the largest number of people.

In French-speaking Belgium, pushing ahead, with MD consensus

Meanwhile, Philippe Kolh, M.D., Ph.D., CIO of the University Hospital of Liege, one of the largest cities in French-speaking Belgium (known as Wallonia), shared with the audience how it is that he and his colleagues have reached a documented Level 6 on the EMRAM scale of HIMSS Analytics. As Dr. Kolh explained, his hospital is the only academic medical center in Wallonia; the other six in Belgium or in Flanders, the Flemish- (Dutch-) speaking part of the country, which is governed separately.

The journey for the University Hospital of Liege has been an interesting one, Dr. Kolh said. Twelve years ago, the three-facility academic medical center organization was characterized by centralized hospital management, yet also a lack of centralized clinical IT solutions, and no automation of appointments, with a “very fragmented” clinical information system. But the organization’s leaders invested nearly 15 million euros in an institutional strategic plan, beginning in 2003; and, with the appointment of a new CEO in 2013, progress accelerated. The organization is now entirely paperless for patient care, with strong IT governance, and a constant focus on creating greater efficiency, Kolh said.

What have been the top critical success factors? Kolh cited seven. First, general management support: “If you want to deploy a project like this, you need senior executive support for it as a priority, or you get a lot of resistance to change—and it has to support the patient, the staff, and the institution—optimal care quality; better working conditions and data; and more efficiency,” he said.

Second, there must be a “reorganization of IT structures,” Kolh said. “We have a department board,” he noted, “composed of each operational structure head and chiefs of services—I chair it. We have strategic monitoring of the IT department, monitoring of projects, IT budget management. And,” he added, “we have a ‘department commission,’ composed of a president, the CMO, president of the Medical Council, dean of the Medicine Faculty, the CIO, assistant CIO, department heads, etc., to greenlight activities and projects.”

Third, inevitably, Kolh said, implementation of the electronic patient record, or EPR, must be gradual. At the University Hospital, he helped lead his colleagues in starting with what he called “easy functions: a results server—clinical biology, medical imaging, nuclear medicine and pathology—in pure receive mode. Then we deployed the medical record—that took two-and-a-half years. From the start,” he said, “we decided to move into a paperless model. We have also been integrating up to 200 different medical devices into the EPR. And we are connected to the RSW, the Walloon Region Network. We also provide data analysis. That’s important so physicians can see the academic value of the EPR as well. Real-time bed management. Then drug order and administration [CPOE], and computerized medicine cabinets. CPOE—drug-drug interaction, drug-allergy, drug-lab information.”

The remaining factors that Kolh cited as critical success factors: a strong IT architecture; end-user involvement; support and training structures, and ergonomics, for user-friendliness. Of end-user involvement, he said, “You want to involve the users from the beginning. How can we do that? Each aspect of the project was shared with key stakeholders for input. We have a users’ group with representatives from every department, including doctors and nurses.”

Massive challenges—and opportunities—in Andalusia

Things are moving forward on an even broader scale in Andalusia (Andalucía), the large region that covers the southern quarter of Spain. There, Juan Lucas Retamar Gentil, CIO of the Andalusian Ministry of Health, is leveraging information technology to facilitate changes on a region-wide level. Importantly, the federalist system of Spain gives the regional governments a very large measure of autonomy and control, enabling tremendous flexibility in strategic planning and implementation of projects—though within the limitations of constrained budgets.

Juan Lucas Retamar Gentil speaks at WoHIT2016

“When HIMSS invited me to come talk about the CIO as a regional leader, I thought about things that I’ve initiated since I started my job,” Retamar Gentil told the audience. “Many people see us like the guy from the IT staff. Butwhen you arrive to a position like CIO, it’s not just about IT. You have to design the IT strategy for the organization, but you also have to be fully aligned with the business strategy. I used to talk to people who worked with my organization, and people normally always talked about projects, one at a time, but never talked about the path, where the organization was going. So I took a couple of months to think about where we wanted to go,” he continued. “And I started to talk with the general manager, and the people on the policy staff, to design a strategy for the next three or four years. It wasn’t easy at all, because people started to talk about many different things. But I wanted to make sure everything was aligned. In the end, we got it. But it’s harder to write a short plan than a long one, yes?”

Looking at the broad outlines of what he and his team are facilitating in Andalusia, Retamar Gentil said, “The three main things for me as a regional CIO are to design a good strategy, to build a good team, and to find the resources,” pointing to a graphic of a triangle with strategy, team, and resources, as the three points of that triangle.

“In terms of strategy,” Retamar Gentil said, “I didn’t have time to write a short one, so I wrote a long one instead! Strategy has to be aligned into different lines of action. I wanted everyone to feel a part of the strategy. The IT strategy is a big puzzle, and everyone needed to know in which part of the puzzle he was. And Strategy without tactics is the slowest route to victory, while tactics without strategy is the noise before defeat. And you have to reevaluate the strategy every few months.”

The main principles in the work that he and his colleagues are continuing at the Andalusian Health Service: equity, accessibility, and transparency. “For example, to provide equity to all the citizens, and to the healthcare professionals,” he said, “we had to improve communication to little towns in the mountains. And we had to segment the population through algorithms, to find a better way to assign the budgets. All of that work continues, with progress being made at every step, he noted.

Meanwhile, at eHealth Ireland, MacSuibhne, a psychiatrist, is leading a collaborative of clinician leaders who are attempting to reframe that country’s push into the healthcare future. “You’d think that in a country with a small population like Ireland, it would be relatively easy to create transformative change; but in fact, as elsewhere, a lot of cultural changes have to take place,” he noted. Meanwhile, he and his colleagues are very actively involved in moving forward such initiatives as the Health Tech pre-accelerator, which the organization’s website notes is “an initiative with the aim of surfacing digital health technology that has the potential to disrupt and solve global healthcare challenges. The aim of this initiative was to bring together health and technology experts to work together to find digital solutions to healthcare challenges,” eHealth Ireland’s website notes. Another initiative is coalescing around a national push for e-referral, which could save the Irish as much as 2.6 million euros a year.


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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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