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In Georgia, Helping Physicians Move Forward on MACRA/MIPS, EHRs, and APMs

April 25, 2017
by Mark Hagland
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Dominic Mack, M.D., shares his perspectives on the important work that he and his organization are involved in, in order to help practicing physicians in Georgia meet the future

The Georgia Health Information Technology Extension Center (GA-HITEC) is Georgia's only federally endorsed health information technology center focused on providing technical assistance to providers and hospitals throughout the entire Electronic Health Record (EHR) implementation process and beyond, including assistance with the reporting required to qualify for and receive EHR Incentive Program payments from the federal Centers for Medicare and Medicaid Services (CMS). GA-HITEC's leaders use their expertise to assist practices and hospitals with improving the quality of care for patients and maximizing overall productivity through the meaningful use of EHR systems. Through its work in the HIT arena, GA-HITEC launched Georgia Health Connect (GaHC), a regional health information exchange connecting practices and small hospitals in rural and under resourced areas with disparate EHR systems to the state health information network—a task that would be otherwise difficult to achieve.

Dominic Mack, M.D., a practicing family physician who is co-director of the National Center for Primary Care and an associate professor at the Morehouse School of Medicine in Atlanta, currently serves as the executive director of GA-HITEC and Georgia Health Connect. He has spent many years practicing family medicine in underserved communities of Georgia. Dr. Mack recently spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the current efforts of GA-HITEC and GaHC to help support practicing physicians in Georgia who are delivering care to underserved and indigent communities in Georgia, as they move to fulfill the requirements of the MIPS (Merit-based Incentive Payment System) system under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law. Below are excerpts from their recent interview.

Tell me a bit more about the mission of the National Center for Primary Care?

We’re a research, educational, training, and resource center for health equity. We do a lot of health equity big-data research, and help provide implementation programs to help support the primary care system, for underserved communities. We are here to advance health equity. Our focus is underserved communities, especially rural communities.

Is the National Center’s focus statewide, or national?


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No, the Center’s focus is national. We do a good bit of our work in the Southeast. We have a number of federally focused programs, some of them as broad as 18 states in breadth. Most of the HIT work has been within the state of Georgia.

And we’ve been working with Liaison [the Alpharetta, Ga.-based Liaison Technologies, Inc.] to help implement HIE [health information exchange] in smaller practices and hospitals to serve underserved and under-resourced communities in both urban and rural areas. With MACRA, we’re moving forward to improve quality improvement programs that help them to meet those initiatives. With HIE, we’re looking at analytics that can help them evaluate how they’re performing in relation to the MACRA measures. With regard to GA-HITEC, we’re actually a sub-recipient of federal funding to help smaller practices in Georgia, so we’ll be working with that program. GMCS is the QIO for the state of Georgia. Georgia Medical Care Foundation. They are the QIO for Georgia. They received about $11 million to manage the implementation of this QPP program that CMs is doing in NC, SC, GA, and FL. We are their partner in Georgia. QPP. QPP is MIPS—the Quality Payment Program.

When did this work to help physicians in practice prepare for work with QPP, begin?

It began in March.

And what are you doing, at a very basic level?

We’re providing technical assistance to small practices. In the state of Georgia, there are over 6,000 providers in practices of fewer than 15 providers. We will be working with GMCS to help those 6,000 providers to implement QPP/MIPS over the next four years.

What are the key components of that?

Quality improvement. That area encompasses Advancing Care Information (ACI), which deals with HIT and HIE. We’ll be focusing on ACI and clinical practice improvement with GCMS.

How are you going to be helping them do this?

So for ACI measures, which replace the meaningful use measures, we’ll be helping them to upgrade the technology, improving the functionality, and improving workflows within their practice, for better health information exchange. They have to improve the functionality of the EHR. The EHR is going to have to be more encompassing and to more comprehensively capture patient data, so that it can be analyzed and reported within their record on behalf of patients.

Is there 100 percent adoption of EHRs on the part of physicians in Georgia now?

No, we have about 80 percent adoption right now.

And, per the remaining 20 percent who haven’t yet adopted, you’ll be helping them implement EHRs, correct?

Yes, and the Medicaid program’s meaningful use program is continuing. We’re working with the State of Georgia Department of Community Health—CMS has continued to provide funding to help Medicaid-participating physicians to complete adoption. And the ones who do, with Georgia Health Connect—what we do is not a direct objective of the MACRA program with GMCS; but because we’re an HIE, as Georgia Health Connect, we’re able to help providers connect with information exchange. And that’s what we’re doing with Liaison; we formed our HIE in 2015.

How many physicians and hospitals have been connected live so far through Georgia Health Connect?

We don’t have any hospitals right now; we have about 45 physicians. It’s still in its early stages. We are live with those 45 doctors, and we are connected to the Georgia statewide HIE—GaHC.

What is it that Liaison is helping you to do?

Liaison is providing our technology backbone. We’re not a technology organization; we do the ideation and the customer-facing work. But the connectivity, the service and the maintenance, are provided by Liaison. We started working with them in 2014.

How big are you hoping that GHC will become?

I do hope it becomes big. By the end of this year, we’re hoping to get up to a couple of hundred providers, and then over the next five years, we’d like to get a couple of thousand providers, and some hospitals, on board as well.

What will the biggest challenges be for doctors to get up to speed to gather, analyze, and report their data to the QPP/MIPS?

The smaller the practice, the more difficult it’s going to be. One of the largest barriers will be not just implementing an EHR system, but getting an EHR system that performs in a manner that allows them to obtain the information, analyze the information, and report on the information, effectively. A lot of doctors are doing good work, but now you have to show that you’re doing good work. And taking that next step is a big issue. And it takes personnel to improve your workflows within your practice. And so to improve your patient engagement and your workflows—you do need a staff. You may need to upgrade your staff, for example, to support the different components of the PCMH [patient-centered medical home] model. So getting the additional resources to support changes to your workflow and improve your technology, will be one of the biggest problems.

Do you think most Georgia physicians will be able to ramp up to the mandates in 2018?

They’ve changed a little of it; 2018 is still relatively simple. It’s in 2019 and 2020 that things ramp up.

And are doctors ready for the demands of 2019 and 2020?

Today? No. Probably up to 40 percent of providers really don’t know too much about the program. And on a basic level, there’s a need for awareness, and getting the physicians to report this year. They’re hoping to encourage people to report on all the measures, just to get ready. But I’ve seen articles saying, you just need to report on one measure this year. But doing so wouldn’t help me prepare for next year. So as of today, no, they’re not ready.

Do you think that CMS’s expectations of Georgia physicians are too rigorous, or not?

Let me just leave it at, ‘aggressive.’ We’ve been happy to be on board and to work with CMS on this. The good thing is that they are involved with us with communities that are saying they need more help. But it is definitely aggressive. That’s not just coming from me, but from other physicians. They’ve been inundated with multiple programs, and smaller practices just don’t know how they’re going to meet the requirements. That’s why we’re glad to be involved. And hopefully, we can help them to be successful.

What would CIOs and CMIOs of hospitals and health systems with which some physicians in practice are affiliated, be thinking about right now?

The smaller and rural hospitals are just trying to survive; they’re doing all they can with the resources they have, to help the practices. With the larger health systems, of course, they’ve been buying up practices, and connecting them with their health systems. What I would say to CIOs and CMIOs on behalf of these small practices, is that I would hope that they develop programs that allow the practices to stay in practice. Part of the CMS program is trying to push practices into APMs [advanced alternative payment models]. There are a lot of small businesspeople who want to stay in business. In that context, I’m so glad that they’re talking about these virtual groups in the MIPS program, and I don’t know if they’ve got the definition of that nailed down, but I like the idea of them coming together in groups of 10 or more, so that they can report together. And I’d like for those practices to remain viable and independent.

Is there anything you’d like to add?

We’re just trying to advance the creation of health equity. We just want to make it an equitable playing field for all patients. We try to support the practices that are serving patients. And for us, the technology innovation that’s happened has actually widened the technology gap, so we’re trying to make sure the smaller practices can make use of the same level of technology available to larger practices. And Liaison has been a great partner in that. 

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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.


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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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