Former ONC Coordinator Karen DeSalvo: A New World is Emerging with Consumer-Mediated Data Exchange | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Former ONC Coordinator Karen DeSalvo: A New World is Emerging with Consumer-Mediated Data Exchange

May 24, 2017
by Heather Landi
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During a Bipartisan Policy Center event tied to the release of a BPC report on improving health IT safety, several health IT policy experts shared their thoughts on the role of government and the private sector in improving IT’s role in providing safer care as well as industry progress on interoperability.

BPC is a Washington, D.C.-based think tank and, in its report, the organization called for greater private-public leadership, collaboration and a systems-based approach to improve patient safety and information technology.

Former National Coordinator Karen DeSalvo, M.D., who also served as Acting Assistant
Secretary for Health in the Obama Administration, and Andrew von Eschenbach, M.D., former commissioner for the U.S. Food and Drug Administration (FDA) and now president of Samaritan Health Initiatives, were on a panel discussion, moderated by former U.S. Senate Majority Leader Bill Frist, M.D., following the release of the BPC report and the panelists tackled the issue of how to improve health IT as well as the role consumers play in interoperability.

DeSalvo reflected on how the health IT landscape has dramatically changed in the years since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009.

“The iPhone was barely on the market and we weren’t thinking about technology in the way we use it today,” she said. “As an example of how technology enables the practice of medicine, ask a clinician or a nurse about the ability to do drug-drug interactions” versus looking it up. “We now have tools to support and enable that,” she said, also noting that there is ongoing evidence that clinical decision support (CDS) tools improve the safety of care. And along with electronic health records (EHRs), there has been an explosion of other technology that has come on board in the healthcare space.


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“The IoT (Internet of Things), the information that patients want to put into their systems, all the other devices in the hospital and there is an array of EHRs that are increasingly using shared standards, but we’re not quite there, and they are interacting with other technologies, including technologies regulated by the FDA and others not regulated. We were trying to get to a place where the standards were common on a floor and encourage sharing of information and build the business case so people have a reason for data to flow,” she said.

DeSalvo added, “The reality is, health IT is in an adolescent phase; it’s still clunky. There are clinicians sitting in a clinical room trying to find information and there is still a lot of hunting and pecking going on. We still have a great deal to do to streamline that and reduce some of the noise in the systems, so the signal comes out more clearly, and that’s part of the usability.”

Karen DeSalvo, M.D.

She also acknowledged the documentation burden that many clinicians face when using EHRs, and the need to ensure accurate patient identification. “There is interesting work going on in that space. The data is accumulating, EHRs are making care safer and making the practice of medicine better, but it needs to be smoothed and easier to use the systems. And, we need to make sure we’re linking the right care plans and medications with the right patient, not just in that care setting, but also globally,” she said.

In its patient safety and health IT report, BPC recommended the development of a coordinated public-private leadership effort to set health IT safety priorities. DeSalvo said she agrees that more colllaboration is needed.

“The private sector has to step up and create a safe environment where they can share information about what’s working, what’s not working and how to solve safety issues that arise,” DeSalvo said. “Safety and security kept me up at night. There are people who will report problems but not everybody is going to be a good actor.” She added that there needs to be peer pressure to get everybody to do the right thing. “And, it’s not just the big developers and big health systems that are engaged, you want to make sure you don’t leave anybody behind, such as the rural hospitals and the federally qualified health centers.”

The discussion turned to the challenges of achieving interoperability, and von Eschenbach noted that interoperability issues are as much a cultural challenge as a technical one. “Physicians, and I’ll take the blame as a surgeon, we grew up in a culture that was highly individualistic, today the game is about being a team that has to work together. Whatever part we’re playing, we have to learn to come together and work together in a collaborative, interoperative way.”

Frist asserted that the movement toward value-based payment and value-based care could be a driver for a more team-based culture. “I don’t think you can get there without a team-based culture,” von Eschenbach said, adding, “The reason why it’s so critically important is the data management systems are giving us the toolkit, and we struggle with variability—variation in the diseases, variation in the person with the disease, variation in the treatment—and to manage that variation you need data and information systems to do it. When you do that effectively, you reduce variance, which improves quality for any group of patients.”

The movement to value-based payment is a big driver to get health systems to think about coordination of care, DeSalvo said, as “the more risk you take, the more you need to see on your dashboard where patients are getting care outside of your system” and access to better data often drives a change in behavior, she added.

Interoperability and the Role of Consumerism

DeSalvo surmised that there are two approaches to interoperability, the early way, she said, was getting two systems to talk to each other, yet she sees consumerism playing a large role in the evolution of data exchange.

“The policy that we had, in my time, was to make the data free so it’s interoperable. When we begin to require APIs on the technology systems, that’s an open opportunity for innovation, as it’s also free to be hosted on behalf of a person, a consumer. This model of consumer-mediated exchange creates a completely different window to their health world, and consumers can make sure the data is accurate, and that people on the care team can see it. Interoperability doesn’t have to be two technology systems talking; there’s actually a new world emerging. Patients are hosting the data, as well as scientists, and leveraged by technology and the push and pull in the industry, people are now willing to free that data to put it to good use.”

Further, DeSalvo said, “As ONC Coordinator, I said it, and I’m still saying it, there’s data blocking. You hear it from payers, providers, scientists, and pharma, and at end of the day, this movement toward consumer-mediated exchange, it has some legs and it gives consumers more control in that space.”

Consumers are an integral part of the care team, DeSalvo said, and “giving consumers more power, agency and more interest in the game” will spur more data exchange. “The more their out-of-pocket costs are, the more interested they are in choosing their provider, their service, their access, and they want more and more want access to information, and if they want to use telehealth or choose a new provider, they have that control.”

Von Eschenbach said physicians are often concerned that interoperability standards hinder innovation, yet he asserts that interoperability enables healthcare providers and researchers to innovate through collaboration. “There is this notion about the application of standards, that it can cause us to lose our individuality, creativity and innovation. There is a tension as doctors are practicing and they will say, ‘Don’t tell me how to communicate and regulate me.’ What we’re talking about is creating a standard for the track upon which different railroad cars can run. Everybody can have their own railroad car as long as it’s built in a way that it runs on the same track, that’s the concept of what we’re trying to do here. The innovation occurs within a framework that allows you to share information and be interoperable and be on the same track. It’s not taking anything away, you still have your own innovative approach to whatever systems you are putting in place.”

During a Q&A following the panel discussion, one audience member voiced frustration that interoperability is not a requirement for EHR manufacturers and Frist asked the panelists if government efforts have prioritized interoperability high enough.

“No, we haven’t. As a practicing physician, we need to make systems more user friendly, as in many cases, it feels like they are getting in the way and giving us more work to do,” von Eschenbach said.

DeSalvo said interoperability was her No. 1 priority as ONC Coordinator. “When HITECH passed, the focus of that was to offset the cost of adoption and get them to be used for clinical care and population health and there was very successful work that came out of that. With the infusion of cash into the industry, what resulted was a lot of existing EHRs with proprietary standards blossomed and grew. The focus at the time wasn’t on the shared standards. Since 2014, when I was ONC Coordinator, the budget is about $60 million, and it was a big ship to turn with limited resources, and to pull together the private sector, the federal partners, and build a business case for interoperability.

She added, "It’s going to take a little bit of time, and it’s an important thing to remember that there are minimal resources, and they’ve taken another hit," referring the budget cuts for ONC in the Trump Administration's proposed budget, "I don’t think the work is done.”


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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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