At HIMSS17, Vivek Reddy, Intermountain CHIO, on the Need to Document for Value | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

At HIMSS17, Vivek Reddy, Intermountain CHIO, on the Need to Document for Value

February 22, 2017
by Rajiv Leventhal
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Vivek Reddy, M.D., current chief health information officer at Salt Lake City, Utah-based Intermountain Healthcare, and formerly chief medical information officer at UPMC Health System in Pittsburgh, has long been a proponent of pushing physician documentation reform ahead. 
With recent attention being paid to the amount of time physicians spend in their electronic health records (EHRs)—thus negatively impacting the patient-provider relationship, and also leading to physician frustration and burnout—there is a great desire in the industry to have health IT help the lives of physicians, rather than hinder them. However, Dr. Reddy believes that the bigger issue is that the quality of the documentation is suffering due to the focus shifting away from value. Reddy spoke with Healthcare Informatics at the HIMSS17 conference in Orlando to discuss documentation improvement, changing the dialogue about its value, and more. Below are excerpts of that interview. 
How do you feel about the recent federal and national attention that has been put on the documentation burden that EHRs put on providers? 
I think the technology we have put into our hospitals and our clinics, right now, has largely been focused on making the burden of documenting easier, because there is a preconceived notion that because I need to get paid, I need to enter all of this information. So what's happening is we have now created a sub-industry that propagates and continues this mythology of "I need to write these notes a certain way and make it super easy for physicians," but what we are really doing is losing so much of that quality documentation. We are our own worst enemy in this space because of our focus on it. When thinking about different digital types of technology, these are things that will take us away from thinking about the note as a construct of some sort of thing that we have to follow or fill out these bullet points, and move into a "I have to document to communicate, to help quality care, and make the right care decisions." If we pivoted that way as an industry, we might take a hit from a financial standpoint for some physicians, maybe a hit of 2 percent, 5 percent or 10 percent, but it could change the dialogue about the value of documentation. 
Specifically, how can documenting the "right way" be accomplished?
We all should be taking a step back and asking ourselves why we document what we do. Physicians are trained a certain way to think about clinical problem, but in every other aspect of their life, the way they communicate is totally different. What I would be advocating for is clinicians thinking about communication first, so what if they just wrote two sentences to explain what's going on? What can I do to make things simpler for my patients to understand as they read their notes, or for other caregivers? If we start getting in the habit of brevity, I think you would see the billing loss and the efficiency gain balance each other out. 
The only way the federal level can really play into this is if they completely took away the concept of Evaluation and Management coding. Even if they did that, the sense of needing to put everything in the note for a regulatory reason would probably still exist, so we really need to re-imagine, and the term I like to use is the "communication chart and the billing chart," so if we can figure out a way for organizations to do this, I think you will see a groundswell and actually some new technology that comes into play, with less of a focus on notes and more focus on communication. The federal part would have to be a complete payment reform, and I'm not going to wait for that. 
For you personally, moving from UPMC to Intermountain, and holding key C-suite executive leadership positions at prominent health systems, what have been the biggest lessons learned of late?
One of the best and most important skills I have learned is to be a really good listener and a really good observer. Most of the problems in healthcare today are not technology-related, and technology sometimes can get in the way. Chasing tools doesn't work; if you listen to what people need, and figure out where their problems are with them, it's a much more engaging strategy. I always pride myself on not being the guy on the mountain, but I want to be where the action is and understand the problems. As I build teams, I always tell my teams not to do so much work in your office or on a whiteboard, but go out and talk to people. You will do just as well if you do that. 
What's new about your current role, chief health information officer, compared with your other roles in the past?
The biggest transition is that the CIO and CMIO role of the last 10 years was so laser focused  on optimizing and deploying EMRs, and the CHIO role now is saying alright, you have all this technology that is optimized or sub-optimized in areas, maybe that's not where all the play should be. Maybe if I spend less time tweaking and more time thinking about care re-design, I would be much more effective. My biggest epiphany moment has been the fact that we are so stuck in our current models, so for instance, people can't imagine that a nurse can do these three or four other things. CHIOs have to embrace this concept of "get me a sandbox or a a zone where I can try totally different things" and free up people's mind from that existing construct. So I think the next generation of CIOs and CMIOs have to be about that type of transformational work and creativity in order to be successful. If you're just an EMR guy or gal, that won't work. 
What's the one main concern you have right now above all others, related to the future of healthcare and healthcare IT?
We are really good at fee-for-service healthcare, and I think that it takes a different type of talent to be able to get past that. When I look at industry trends, I think we have a people-talent conversion that we haven't gone through yet, where just the types of people that gravitate to healthcare are in a certain mindset, and we have to infuse new ways of thinking and new processes. We will always have interesting technology challenges as the world evolves, but we will need a personality transplant for all of healthcare in order to think of things more creatively. 
As far as the shift to value-based healthcare, our CEO at Intermountain always says that if you do the right thing, you usually win. This transition is always focused on what our patients need and getting the best outcome. You cannot be focused on if you had a bad quarter or month, and thus have to change strategies. Intermountain is great at staying grounded, and if it's the right thing, great, and we might fail along the way and have to pivot, but just do the right thing. 

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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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