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How Geisinger Created a Patient-Facing Genomic Test Report in Its Patient Portal

June 7, 2018
by David Raths
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Geisinger exec sees promise in SMART on FHIR, new genomics features in Epic upgrade
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Pennsylvania-based Geisinger Health is partnering with the Regeneron Genetics Center to perform exome sequencing on as many as 250,000 Geisinger patients over the next five years. That fact increases the urgency of communicating the results with patients and providers. The integrated health system created its own patient-facing genomic test report (PGR) within its Epic EHR ecosystem using a web application interface also created internally.

In a recent article in the open access journal BMC Medical Informatics and Decision Making, a Geisinger team described the process of creating the PGR. In a recent interview with Healthcare Informatics, Marc Williams, M.D., director of the Genomic Medicine Institute at Geisinger, spoke about the issues they are seeking to address and the informatics challenges.

I asked Williams if Geisinger has experienced the challenge of patients and providers not having access to clear communications about results.

He responded that it is well known that current genetic test reports are very difficult for non-genetic clinicians to interpret and that some of them are almost impenetrable for genetic clinicians. They are clearly not designed for use by patients. “We are in a scenario where both patients and providers are being exposed to a report that is probably not useful and at worst confusing, which could lead to inaccurate interpretation and use, so we wanted to have something to improve the ability to interpret the information.”

Another challenge, he added, is that the ability to represent the genetic test reports in any way that would allow clinical decision support is not available currently. “We are essentially getting PDFs of lab reports, so you can’t do much with them,” he said.

One of the challenges the Geisinger team faced was putting the results in the right level of complexity and detail that is easily comprehensible both by patients and by their providers. The lab reports themselves are long and complex. “We thought there needed to be an interpretive report presented in addition to the laboratory reports. It is important to understand that these reports are not meant to replace the actual lab report. These are used to provide information in a more comprehensible format to the patient and provider. We designed the interpretive reports based on input we got from patients and providers. Their format is informed by what patients and providers said they wanted.”

To create the reports, Geisinger used an authoring tool called Compass that was originally developed as a tool to improve communications between patients and providers. It allowed patients with conditions such as congestive heart failure to enter patient-reported information, such as diet or daily weight. “It was looked at as a disease management tool available within the electronic health record through launching an application interface,” Williams explained. It is a standards-based tool that can extract information from the EHR and return information to portions of it.  “We thought we could leverage Compass for genetic interpretive reports. This was the most expeditious way to get that report launched in both the patient portal and EHR.”

Williams said the development team took advantage of OpenInfobutton, an open source suite of Web services that enable infobutton capabilities within EHR systems. Geisinger is involved with the Clinical Genome Resource, or ClinGen, which is dedicated to building an authoritative central resource that defines the clinical relevance of genes and variants for use in precision medicine. “I have been leading some work on the EHR interface between the ClinGen resource and certified EHRs. We have a huge amount of knowledge encompassed within the ClinGen but also linked to other knowledge repositories,” Williams explained. “We sought to move this into the EHR environment and present it to patients and providers. OpenInfoButton is a very useful tool in that regard in that it is supported through Meaningful Use in certified EHRs. We could configure the resources to be accessible to OpenInfoButton calls, so we did a lot of work to make the ClinGen resources available for queries through OpenInfoButton. By enabling that, we don’t have to create all the content for Compass reports. We can pull in either through URL or OpenInfoButton, information that is relevant to certain content areas in the Compass report.”

Because SMART on FHIR Genomics is emerging as a genomic-specific HL7-approved standard, Geisinger is now exploring the use of SMART on FHIR capabilities in the reporting process.

“We think there is a lot of promise to SMART on FHIR,” Williams said. “It may allow us to move away from a relatively clunky interface in the sense that if you want to use the Compass report, the provider has to launch it out of Epic. It is not enabled within the workflow. It requires extra work to do it. If we can use something like SMART on FHIR, we might be able to integrate this information directly within workflow without having to launch an external interface.  What we want to do is take advantage of things, whether it is OpenInfoButton, Smart on FHIR, or other technologies coming down the road that are going to be incorporated as standards within the EHR and allow us to incorporate this information within the clinician workflow and present to the patient without a lot of extra work.”

Williams noted that an upgrade to Epic planned for later this year offers opportunities will provide more functionality related to genetics and genomics. “There is going to be opportunities to represent some of these results as structured data,” he said. “We are going to be able to take advantage of things like InfoButton, which are already incorporated into Epic, and build the resources without having to use the Compass application. The decision has been made to look to integrate functionality within the upgrade of Epic. All of the content being developed can be easily deployed, whether through an OpenInfoButton interface or SMART on FHIR interface supported through the EHR. So essentially we are going to be able to deliver the same information, but through a much slicker interface than Compass can currently deliver.”

I asked Williams about another informatics challenge: a lack of tools in the EHR to do family history reports as structured data.

It is still a problem, he said, but at least for Epic, in the next release, they will have a much more robust family history module than has been previously incorporated. “I think we are making some progress in that area. We have been exploring other ways we can incorporate family history.” For example, Geisinger has deployed a suite of risk stratification tools for breast and ovarian cancer assessment within its mammography information system. “If there is evidence of any family history or other increased risk where genetic consultation should be considered, that is now part of the routine report in the hands of the radiologist,” he said. “We are looking at a variety of strategies to improve what we are doing with family histories.”

 

 

 

 

 


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Study: Clinical Decision Support EHR Alerts Can Lower Health Costs, Complications

August 20, 2018
by Rajiv Leventhal
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When physicians follow the recommendations of context-specific clinical decision support at the point of care, clinical and financial outcomes should improve, according to new research.

Researchers, in the recent study, published in the American Journal of Managed Care, examined more than 26,000 patient encounters to determine whether utilization of clinical decision support (CDS) is correlated with improved patient clinical and financial outcomes. In the treatment group, the provider adhered to all CDS recommendations, while in the control group, the provider did not adhere to CDS recommendations.

The analysis examined the associations between adherence to recommendations from Choosing Wisely—a clinical decision support platform from Stanson Health—embedded into clinical decision support alerts, and four measures of resource use and quality.  They found and concluded:

  • Encounters in which providers adhered to all alerts had significantly lower total costs, shorter lengths of stay, a lower probability of 30-day readmissions, and a lower probability of complications compared with nonadherent encounters.
  • Full adherence to Choosing Wisely alerts was associated with savings of $944 from a median encounter cost of $12,940.
  • Health systems should consider real-time CDS interventions as a method to encourage improved adoption of evidence-based guidelines.

In 2012, the ABIM Foundation—a healthcare quality organization devoted to advancing medical professionalism—introduced the Choosing Wisely (CW) initiative, a voluntary effort by more than 70 physician subspecialty societies to identify commonly used low-value services, with the intent to stimulate provider–patient discussions about appropriate care and thereby reduce low-value tests and treatments. But initial research of the CW recommendations found that providers had difficulty interpreting guidelines and evaluating patient risk.

To this end, the researchers attested that an EHR (electronic health record) infrastructure could provide real-time computerized clinical decision support to inform healthcare providers when their care deviates from evidence-based guidelines. CDS comprises a variety of tools, including computerized alerts and reminders with information such as diagnostic support, clinical guidelines, relevant patient information, diagnosis-specific order sets, documentation templates, and drug–drug interactions.

For this study, CW recommendations were implemented in the EHR at a large academic health system in the form of 92 alert-based CDS interventions, both inpatient and ambulatory. When initiating a potentially inappropriate order, a provider received real-time notification of deviation from a CW recommendation. That provider then had the option to cancel, change, or justify the order, if he or she agreed with the alert’s recommendation in the context of the individual patient.

It should be noted that two of the study’s authors are employed by Optum, which is a licensed reseller of Stanson Health, including its Choosing Wisely alert content evaluated in this study. What’s more, another of the authors is employed by Cedars-Sinai, which is the major shareholder of Stanson Health.

In the end, the researchers recommended that health systems consider real-time CDS interventions as a method to encourage improved adoption of CW and other evidence-based guidelines. A meta-analysis of CDS systems concluded that by providing context-specific information at the point of care, the odds of providers adopting guideline recommendations are 112 times higher.

They concluded, “Our findings contribute to the evidence base surrounding the use of CDS and improvements in patient clinical and financial outcomes. Formal prospective cohort studies and randomized CDS intervention trials, perhaps randomizing providers assigned to receive CDS interventions, should be prioritized to help guide future provider strategies in regard to reducing low-value care.”

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Study: Many U.S. Hospitals won’t Reach HIMSS Stage 7 Until 2035

August 14, 2018
by Rajiv Leventhal
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Unless the healthcare IT ecosystem experiences major policy changes or leaps in technological capabilities, many hospitals will not reach Stage 7 of HIMSS Analytics’ Electronic Medical Record Adoption Model (EMRAM) until 2035, according to new research.

The study, published in the August edition of the Journal of Medical Internet Research, analyzed Healthcare Information and Management Systems Society (HIMSS) Analytics’ EMRAM data from 2006 to 2014.

HIMSS Analytics is the research arm of the Healthcare Information and Management Systems Society (HIMSS). HIMSS Analytics developed the EMRAM in 2005 as a methodology for evaluating the progress and impact of electronic medical records on health systems around the world. Tracking their progress in completing eight stages (0-7), hospitals can review the implementation and utilization of information and technology applications culminating with Stage 7, which represents an advanced electronic patient record environment. Other Stage 7 requirements include: leveraging an external HIE (health information exchange); use of a data warehouse; and having robust data analytics functions.

The researchers of this study noted that the meaningful use (MU) program has promoted electronic health record (EHR) adoption among U.S. hospitals. And while studies have shown that EHR adoption has been slower than desired in certain types of hospitals; generally, the overall adoption rate has increased among hospitals.

However, the researchers continued, these studies have neither evaluated the adoption of advanced functionalities of electronic health records (beyond meaningful use,) nor forecasted EHR maturation over an extended period in a holistic fashion. “Additional research is needed to prospectively assess U.S. hospitals’ electronic health record technology adoption and advancement patterns,” the researchers stated.

The HIMSS EMRAM data set was used to track historic uptakes of various EHR functionalities considered critical to improving healthcare quality and efficiency in hospitals. A technology diffusion model was then used to predict the technological diffusion rates for repeated EHR adoptions where upgrades undergo rapid technological improvements. The forecast used EMRAM data from 2006 to 2014 to estimate adoption levels to the year 2035.

In 2014, more than 5,400 hospitals completed HIMSS’ annual EMRAM survey (86 percent of total U.S. hospitals). Back in 2006, the majority of the U.S. hospitals were in EMRAM Stages 0, 1, and 2. But by 2014, most hospitals had achieved Stages 3, 4, and 5, the study noted.

The researchers found that in 2006, the first year of observation, peaks of Stages 0 and 1 were shown as EHR adoption precedes HIMSS’ EMRAM. By 2007, Stage 2 reached its peak. Stage 3 reached its full height by 2011, while Stage 4 peaked by 2014. This forecast indicates that Stage 5 should peak by 2019 and Stage 6 by 2026, according to the data revealed in the study.

The researchers noted, “Although this forecast extends to the year 2035, no peak was readily observed for Stage 7. Overall, most hospitals will achieve Stages 5, 6, or 7 of EMRAM by 2020; however, a considerable number of hospitals will not achieve Stage 7 by 2035.” They concluded, “These results indicate that U.S. hospitals are decades away from fully implementing sophisticated decision support applications and interoperability functionalities in electronic health records as defined by EMRAM’s Stage 7.”

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HHS OIG Fines eClinicalWorks $132,500 For Violating Corporate Integrity Agreement

August 1, 2018
by Heather Landi
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The Health and Human Services (HHS) Office of Inspector General (OIG) fined electronic health record (EHR) vendor eClinicalWorks $132,500 for failing to report patient safety issues to the regulatory body as reportable events in a timely manner.

According to the OIG website, eClinicalWorks paid the fine July 18. The EHR vendor is required to report these patient safety issues to OIG as part of its corporate integrity agreement (CIA) with the agency.

eClinicalWorks entered into a CIA back in May 2017 as part of a settlement with the U.S. Department of Justice to resolve a False Claims lawsuit. According to the DOJ’s case, the company allegedly violated federal law by misrepresenting the capabilities of its software and for allegedly paying kickbacks to certain customers in exchange for promoting its product, according to the U.S. Department of Justice. As part of that settlement, eClinicalWorks also paid a $155 million settlement over the allegations.

The five-year CIA requires, among other things, that the company retain an Independent Software Quality Oversight Organization to assess eClinicalWorks’ software quality control systems and provide written semi-annual reports to OIG documenting its reviews and recommendations. The company must provide prompt notice to its customers of any safety related issues and maintain on its customer portal a comprehensive list of such issues and any steps users should take to mitigate potential patient safety risks.

Further, the agreement also requires eClinicalWorks to allow customers to obtain updated versions of their software free of charge and to give customers the option to transfer their data to another EHR software provider, without penalties or service charges. The vendor must also retain an Independent Review Organization to review its arrangements with healthcare providers to ensure compliance with the Anti-Kickback Statute.

 

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