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Health IT Stakeholders Have Different Takes on Changes to EHR Certification Program

September 25, 2017
by Heather Landi
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The Office of the National Coordinator for Health IT (ONC) announced on Thursday updates to the Health IT Certification Program with the aim of making it easier for health IT vendors to get their products certified.

As previously reported by Healthcare Informatics, the changes signal that ONC it will relax its oversight of how well electronic health records (EHRs) meet government standards. In making these changes, ONC, which is a part of the U.S. Department of Health and Human Services (HHS), aims to improve the program’s efficiency and reduce burden on health IT developers and users. The goal, the agency said, is to enable health IT developers to devote more of their resources and focus on the remaining interoperability-oriented criteria, aligning with the tenets of the 21st Century Cures Act, ONC officials said.

Providers are required to use a certified EHR in order to be compliant with meaningful use regulations.

The agency said it will allow health IT companies to “self-declare” that their products meet 30 of the 55 criteria needed in order to get their products certified. The second change will ease requirements for random surveillance of health IT by ONC-Authorized Certification Bodies (ACBs).

An ONC webpage outlining 2015 Certification testing and test methods features an updated chart indicating exactly which criteria no longer require a test tool.

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“This means that health IT developers will self-declare their product’s conformance to these criteria without having to spend valuable time testing with an ONC-Authorized Testing Laboratories. This testing typically included either a visual demonstration of the product’s functionality or submission of documentation confirming the required functionality,” Elise Sweeney Anthony, director of ONC’s Office of Policy, and Steven Posnack, director of ONC’s Office of Standards and Technology, wrote in an ONC Health IT Buzz blog post.

The ONC officials note that self-declaration is not a new approach and is used among other industry testing programs. The test procedures for health IT products now designated as “self-declaration” are for functionality-based certification criteria.

Many health IT vendors voiced support for the program changes and hope that it signals a broader reform of the Health IT Certification program. Sasha TerMaat, chair of the EHR Association and director at Epic Systems, said in a statement, “We have encouraged ONC to look for ways to make the certification process less expensive and more efficient. We therefore appreciate the direction and intent of the proposed changes, and look forward to reviewing the details of this new approach.”

Stephanie Zaremba, athenahealth's director of government and regulatory affairs, says, “At a high level, we were happy to see ONC doing some things to reduce the burden that the certification process places on developers, but more so on the providers.” Zaremba says a highly-prescribed certification process results in health IT functionality “that is clunkier" for provider end-users. And, she added, “For every extra hour we put into testing of certification, that’s an hour that we’re not putting into something that our customer has specifically asked for. We’re happy to see them taking steps in the right direction on this. We’re also looking forward to seeing these changes as just one piece of a strategy in a broader reform of the certification program.”

Zaremba said ONC has an opportunity to support “good business and good technology processes that align even more closely with the constantly evolving government payment programs.” Also, she added, “More can be done in the certification program to really encourage innovation in service of providers and patients.”

Many health IT industry stakeholders said they still reviewing the changes, but many voiced concerns about ONC scaling back its oversight of EHR certification and the potential impact to patient safety. At the same time, some health IT stakeholders worried that the relaxing of oversight of certification requirements would pass the responsibility onto providers to uncover deficiencies.

Robert Tennant, director of health information technology policy at the Medical Group Management Association, notes that MGMA “strongly supports a robust oversight process from ONC” and that the ONC decision to relax its oversight comes on the heels of the eClinicalWorks settlement of a False Claims Act lawsuit. Back in May, the U.S. Department of Justice announced a settlement that holds eClinicalWorks, and the company’s founders and executives, liable for payment of $155 million to resolve a False Claims Act lawsuit. The complaint alleges eClinicalWorks falsely attested to its certifying body that it met certification requirements under the Meaningful Use program, and in turn caused its healthcare provider customers to make false claims for incentive payments under the Meaningful Use program.

“The question is not just eClinicalWorks, but the question for a lot of medical groups is, if that major vendor had issues, are they the only ones?” Tennant asked. “We’re not convinced that having lax oversight is the best thing, not just for the program, but also for two aspects for medical groups. One is, of course, the considerable financial investment that practices make in these technologies; it takes years to identify, to negotiate, to implement these technologies.” Second, he says, “there are implications for patient safety. If the software does not do what they claim it will do, it could have an impact on the care delivery process, and that to us is simply unacceptable."

Tennant continues, “As ONC is trying to make it a little bit easier on the administrative side for software vendors, we would encourage them, at the same time, to continue to be aggressive to ensure that these vendors are accurately reporting their certification data and that the software does what the vendor claims it will do, both on the operational side but also focused on the safety of the patient.”

Tennant adds, “I have no issue with self-attestation, certainly that’s a component for physicians and other clinicians participating in things like Meaningful Use and MIPS (the Merit-based Incentive Payment System). But, with physicians, of course, there is an audit program, so if they attest to meeting, for example, MU, they understand they could be audited. That oversight is an important aspect of the program; it applies certainly to the software vendors as well. So, we’re not opposed to self-attestation, but that comes with a requirement we believe that the government continue to provide that oversight.”

Tennant specifically points to ONC’s Certified Health IT Product List website, which has a feature that lists all the health IT products for which a non-conformity has been recorded and the products’ vendors must complete a corrective action plan. A certified product is non-conforming if, at any time, an ONC-ACB or ONC determines that the product does not comply with a requirement of certification and developers of those certified products must take approved corrective actions to address such non-conformities. The list includes 108 vendors that are currently under a corrective action plan. Further, the ONC site also lists decertified products, of which there are 61.

“When I see that, it tells me that the vendor community needs to be aware that the government is prepared to take action. And, obviously, decertification is a last resort, because it’s harmful not only to the vendor, but harmful to the physicians who have purchased the product. This is why a lot of the enforcement action has been in the form of a corrective action plan from ONC. But the sheer number of these corrective action plans tells me that there may be a pretty broad swath of vendors that are not meeting the requirements of the certification,” Tennant says.

Zaremba says she believes athenahealth’s objectives, the health IT industry’s objectives and regulators’ objectives are aligned in terms of wanting to further the cause of having technology help further patient care. “It’s just a question of continuing the conversation on how we get there,” she says. And, she notes, “I would say that the goal should be having the right oversight. So, doubling down and doing more and more of the wrong kind of oversight, certification, that’s not going to help patients. But we are looking forward to partnering even more with ONC and we want their processes to promote patient safety and to promote good services to clinicians.”

 

 

 

 

 

 


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How BI Tools Are Helping Jefferson Health Battle the Opioid Crisis

September 21, 2018
by David Raths, Contributing Editor
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Helping clinical leaders identify prescribing patterns across the health system

Making health system changes to address the opioid crisis is challenging if you don’t have actionable data about prescribing patterns. With guidance from their chief medical officer, the business intelligence team at Jefferson Health in Philadelphia took advantage of the recent enterprise EHR implementation to create dashboards highlighting potential prescribing issues. Internal EHR development teams have already made changes to address the issues they found.

In a recent interview, Cara Martino, enterprise business intelligence manager at 14-hospital Jefferson Health, said that Jefferson was one of the first health systems to implement its Epic EHR and Qlik Sense at the same time. Many organizations that go live on Epic use Crystal Reporting, she said. “It was the combination of the two that allowed us to do this project,” she added. Before going live on Epic and using this new BI tool, Jefferson clinicians used a bunch of disparate systems for ambulatory, inpatient and emergency department physicians. “We weren’t able to aggregate the data,” she recalled.

Jefferson departments had tried to look at opioid prescribing previously, but “they were trying to manually abstract opioid data from the system, compile it in Excel, and try to see trending across the continuum of care, but they really weren’t able to do that very well,” Martino said. “Once we went live with Epic, we were able to standardize the work flow of entering the opioid order and prescription, and Qlik Sense allowed us to look at it from that enterprise view and to slice and dice the data a bunch of different ways.”

In response to the opioid epidemic in the Philadelphia area, Jefferson has created an opioid task force. In January 2018, Edmund Pribitkin, M.D., Jefferson’s chief medical officer, came to the BI team because he saw they didn’t really have good data to share. “We were bringing physicians and pharmacists together in a room to think through what we can change to address the opioid crisis,” Martino said, “but they didn't’ have baseline data to understand where we are going wrong.”

Pribitkin asked the BI team to develop a high-level dashboard with five key metrics to share at the clinical chair department level: 

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• Prescriptions by provider and service;

• Number of orders with over 100 pills;

• Prescriptions written for more than 7 days, 5 days and 3 days;

• Patients with two or more opioid prescriptions within 30 days; and

• Morphine-equivalent daily doses over 50.

The metric around patients with two or more prescriptions within 30 days had been difficult to see when data was being entered in a lot of different ordering systems, but is much easier now because everyone is ordering through Epic.

Within a month, the BI team had a prototype created. In the dashboard, you can pick a patient with the most scripts, and below it populates the different providers who are prescribing for them. “Sometimes you pick someone on the higher end and only one person is prescribing to them. Usually it is a chronic pain clinician, and it is probably appropriate,” Martino said. “But then you pick someone who has six different providers providing them opiates. They may have no idea about each other. Now we get to have that conversation about what we can do in the EHR to notify them at the time of ordering that the patient already has something prescribed. Also, our quality department can notify these six providers via e-mail. They might ask whether we should refer this patient to a chronic pain physician. If they really need this much pain medication, are we treating them the right way?”

Showing clinical leaders a trending graph such as prescription orders of 7 days or more can have an impact on ordering trends and EHR recommendations. Martino, who is a nurse herself, described an example of how her team worked with clinician informaticists who build EHR workflow tools to make some key changes.

They saw in the data that there were examples of doctors were prescribing six opioids to the same patient within two minutes. On further examination, they found that clinicians were entering orders incorrectly and quickly canceling them. But the e-prescription interface with the pharmacy system wasn’t necessarily canceling the incorrect orders, and the patients could have six prescriptions waiting for them at the pharmacy.

“Our first step was to get a message out to providers to let them know if you are prescribing and sending to an outside pharmacy, you need to pick up the phone and talk to the pharmacy about a change in an order and make sure they know which is the correct one,” Martino said. They also worked on the pharmacy interface to generate those canceled order messages, so that if something is ordered and then canceled within 30 seconds, it alerts the pharmacy not to prepare it.

The BI team saw another EHR change that they thought might make a big difference in prescribing patterns. In the EHR quick buttons, duration of the prescription defaulted to 10 days. The quick button on order days had choices of 7, 10, 15 or 30. “We knew those were too high,” she said. “We wanted 3, 5 or 7.”

They worked with an emergency department doctor who was also an informaticist to pilot that change in the ED. “In the first month, we saw a drop from 32 scripts over 7 days to just two,” Martino said. The following month they saw a reduction of more than 65 percent in prescriptions of more than 7 days. “The best part is no one complained or said they were looking for the 10 button and it wasn’t there,” she added. Now that change is being rolled out enterprise-wide.

Although there are some other requests from clinicians for data about opioid prescribing, Martino said the BI team’s current goal is to help more clinicians gain insights into the data that already exists. “It is really hard to go from an institution that was not data-rich and had disparate systems and manually collected data to one that has one EHR and a robust BI tool that allows us to slice data in a million different ways,” Martino said. “We are trying to get the clinicians comfortable with the tools. There is so much we can do, but we have to get the data to the right people and educate them about how we are pulling it out of the EHR. It is easy for this not be a priority for clinicians because they are so invested in taking care of their patients. It is our job as informaticists to go to their meetings and talk about changes we can make. It is also important for us to have clinicians on our team and to be able to offer that informaticist viewpoint.”

 

 


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Survey: Physicians Sour on Value-Based Care Metrics, EHRs

September 19, 2018
by Rajiv Leventhal, Managing Editor
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They new research has several key findings related to value-based care, health IT and burnout

More than 50 percent of U.S. physicians who receive value-based care compensation said they do not believe that the metrics the reimbursement is tied to improve the quality of care or reduce costs, according to a new survey.

The research comes from The Physicians Foundation, an organization seeking to advance the work of practicing physicians and helps them facilitate the delivery of healthcare to patients. The Foundation’s 2018 survey of U.S. physicians, administered by Merritt Hawkins and inclusive of responses from almost 9,000 physicians across the country, reveals the impact of several factors driving physicians to reassess their careers.

Specifically, the new survey underscores the overall impact of excessive regulatory/insurer requirements, loss of clinical autonomy and challenges with electronic health record (EHR) design/interoperability on physician attitudes toward their medical practice environment and overall dissatisfaction—all of which have led to professional burnout.

The research revealed several key findings, including that value-based compensation is directly connected to the overall dissatisfaction problem, which is tied to metrics such as EHR use, cost controls and readmission rates, etc. Forty-seven percent (compared to 43 percent in the 2016 survey) of physicians have their compensation tied to quality/value, but when physicians were asked if they believe that value-based payments are likely to improve quality of care and reduce costs, 57 percent either disagreed or strongly disagreed that this is the case, while only 18 percent either agreed or strongly agreed that it is.

As one responding physician put it: “We are no longer in the business of healthcare delivery, we are in the business of ‘measures’ delivery.” More than 13 percent of physicians are not sure if they are paid on value.

What’s more, the research found that 88 percent of physicians have reported that some, many or all of their patients are affected by social determinants. Conditions such as poverty, unemployment, lack of education, and addictions all pose a serious impediment to their health, well-being and eventual health outcomes. Only one percent of physicians reported that none of their patients had such conditions.

Additional notable findings from the research included:

  • 18.5 percent of physicians now practice some form of telemedicine
  • 80 percent of physicians report being at full capacity or being overextended
  • 40 percent of physicians plan to either retire in the next one to three years or cut back on hours—up from 36 percent in 2016
  • 32 percent of physicians do not see Medicaid patients or limit the number they see, while 22 percent of physicians do not see Medicare patients or limit the number they see
  • 46 percent of physicians indicate relations between physicians and hospitals are somewhat or mostly negative

Coupled altogether, 78 percent of physicians said they have experienced burnout in their medical practices, according to the survey’s findings. And the results show that one of the chief culprits contributing to physician burnout is indeed the frustration physicians feel with the inefficiency of EHRs.

“The perceptions of thousands of physicians in The Physicians Foundation’s latest survey reflect front-line observations of our healthcare system and its impact on all of us, and it’s sobering,” Gary Price, M.D., president of the Foundation, said in a statement. “Their responses provide important insights into many critical issues. The career plans and practice pattern trends revealed in this survey—some of which are a result of burnoutwill likely have a significant effect on our physician workforce, and ultimately, everyone’s access to care.”

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Brigham Health’s 3-Pronged Approach to Reducing EHR’s Contribution to Burnout

September 18, 2018
by David Raths, Contributing Editor
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Focus is on individualized training, reducing unnecessary clicks, voice recognition tools

Research studies have found that “burnout” is nearly twice as prevalent among physicians as among people in other professions.  Physician surveys have found that 30 to 60 percent report symptoms of burnout, which can threaten patient safety and physician health. With EHR documentation ranked high among aspects of their work physicians are dissatisfied with, Brigham Health in Boston has taken a three-pronged approach to reducing the pain.

Brigham Health, which is the parent organization that includes Brigham and Women’s Hospital, Brigham and Women’s Faulkner Hospital and the Brigham and Women’s Physicians Organization, rolled out its implementation of Epic in 2015. In a Sept. 18 presentation that was part of the Harvard Clinical Informatics Lecture Series, Brigham Chief Information Officer Adam Landman, M.D., said the organization’s initial EHR physician training was eight hours of classroom training on where to find things in the EHR instead of focusing on workflows and how to use the EHR to support it.  “Our experience was not the best,” Landman admitted.  They followed up with tip sheets, a help desk and a swat team to do service calls, but providers only rated those interventions as somewhat helpful, so Brigham informaticists re-doubled their efforts to:

• Improve the EHR;

• Provide one-on-one training in the clinical setting; and

• Offer voice recognition software and training.

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Landman said IT teams at Brigham feel a sense of urgency about reducing the burden of EHR documentation. “Burnout is an epidemic, and the EHR is a component of this,” he said, adding that the changes are not just a one-year cycle but must involve continual iterative improvements. “We need to be more aggressive about making changes,” he said.

He described some efforts to reduce notifications and remove clicks from the medication refill process. They also removed a hard stop when discontinuing a medication. Those three changes alone reduced the number of clicks per month by 950,000 across the health system.

They also worked to reduce clinical decision support alerts with very low acceptance rates by turning them off. Three alerts with very low acceptance rates were turned off. “If we thought they were important, we would fine tune them to increase the acceptance rate,” Landman stressed. “That is part of clinical decision support lifecycle management. But we will continue to iterate to reduce the number of unnecessary clicks.”

A year and a half ago, Brigham also created a one-to-one support program, in which an expert trainer would meet the physicians in their practice and help them with their work flow. A pilot project involved four specialties, including general surgery. Each session was 90 minutes to two hours long, and providers were offered one or more follow-up sessions, as well as optional training on speech recognition. After seeing some negative feedback on their initial classroom training, the one-to-one sessions were met with a very positive response. Almost 95 percent said it was valuable, and 95 percent said they thought their efficiency with the EHR would improve following the training. Based on that early success, the training effort is now being rolled out to much larger groups of physicians at Brigham and across the Partners HealthCare network.

In another attempt to improve documentation turnaround time, Brigham has made voice recognition tools and training available to physicians. They made two-hour training sessions mandatory for those interested in adoption, with additional personalization sessions also available. Informaticists partnered with departments to build department-specific order sets. (Brigham also started offering 15-minute e-learning sessions for residents.) More than 90 percent of surveyed physicians said the training met expectations, and 70 percent said they would be willing to have additional training, Landman said. Currently 5,000 physicians across Partners are trained to use voice recognition tools with the EHR.

Landman also cited a study that compared U.S. and international use of Epic that saw a huge disparity in length of documentation notes. The U.S.-based users’ notes were nearly four times longer on average than those of their international counterparts. Epic users overseas tend not to complain about the burden of documentation, he noted. This has to do with how the provider notes are used in billing, he said, adding that CMS is working on proposals to change billing requirements that may alleviate some of the documentation burden for physicians.

In closing, Landman urged informatics colleagues to think about working on EHR optimization research and studying the impact of policy and technology changes. “New technology tools can seem fun and exciting, but for physicians who see up to 100 patients per day, they can be quite overwhelming,” he said. “We don’t want physicians spending half their time doing administrative work.”

 

 

 

 

 


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