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How a Virtual Scribe Can Enhance the Doctor-Patient Relationship

February 2, 2017
by Rajiv Leventhal
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Although the influx of electronic health records (EHRs) in physician practices over the last several years has had constructive effects on many aspects of patient care, this technology movement does have its drawbacks too: in doctors’ exams rooms these days, patients often find their doctor’s attention is being focused on a computer or laptop. As such, some doctors have hired scribes, assistants to make notes into the computer while the doctor speaks with the patient; others enter the information themselves as they talk to the patient.

For small and solo physician practices especially, the negative side effects of their EHR implementation—such as the burdens of data entry and box-checking—surely hit harder than they do for larger patient care organizations that can better shoulder the costs with the resources to bring in more physicians. But for these health systems’ smaller brethren, the constant attention being paid to the IT systems can hurt the doctor-patient relationship. Par Bolina, M.D., chief innovation officer at New York City-based healthcare solutions company IKS Health, compares the lack of face-to-face interaction to “doctors who text while driving.”

IKS Health’s virtual scribe technology is currently being used by more than 200 physicians in the U.S., one of them being Ryan Jones, M.D., an internist at USMD Medical Clinic of North Texas. Jones started piloting the virtual scribe software last January after hearing about the potential of the service from other doctors at a medical conference. “Just trying to get everything done that a primary care physician encompasses is virtually impossible in the scope of one day. Any help is welcome,” Jones says.

The technology specifically works by installing microphones in the exam room that record the patient and doctor discussion, which then automatically transcribes the visit into an EHR for follow-up care. Jones says that at the beginning of every patient encounter, the nurse goes in the room to get his or her consent. Then, the recording begins when Jones comes in herself, though the patient has the right to ask for the microphone to be turned off at any time. After the patient visit is completed, the recorded encounter gets sent to a team of medical professionals who Jones works with in India, who listen to the recording and turn it into a “thoughtful note.” Those files are then transferred to IKS where they are encrypted; this security measure means they are not able to be played on any terminals outside of IKS’ network.  Jones will review the note the next day and approves of the coding, such as tests that need to be done or medications that need to be managed.

What helps the progression go smoothly is that the outside team in India is comprised of all MDs, so Jones says they are able to process the note in the same way that she would, despite a rocky beginning in which back-and-forth calls between Jones and the team took place every day. “But after a few months, there was hardly anything to edit; we’re on the same page. It flows very nicely,” she says.


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...

Ryan Jones, M.D.

Prior to deploying the technology, Jones says she was always doing the notes herself. She had a computer in the exam room and was typing while at the same time talking to the patient, thus doing the majority of the note while being in the room with the patient. “I would have to finish some of the chart at home during the night; I was trying to strike a balance between attempting to make eye contact with the patient and typing a coherent sentence. “But with this [approach], the notes weren’t pretty at the end of the day. It was a hard balance to strike,” Jones says. “A few times I brought my nurse in with me to do some of the typing while I saw the patient, but that was never the most comfortable for the patient, and the nurse had a million other tasks to do outside of the exam room. So I didn’t think that was a very viable option.”

But now, with the virtual scribe, Jones says that the quality of her notes is drastically improved. “I am always strapped for time, so I am now able to articulate my thoughts while I’m in the exam room with the patient. And the patients love that; they hear your thought process as you are describing it for the scribe, because all of the documentation is done during the patient encounter. It’s not like the old system where you leave the room and dictate the note after the patient leaves. It’s all in front of the patient,” she says.

What’s more, Jones isn’t the only one benefiting from the software assistance. According to Dr. Bolina, the collected and measured outcomes from all physicians who have used the virtual scribe service in the last year have proven very positive, including: a 65 percent decrease in documentation time (which translates into about 1 to 2 hours of time saved per doctor per day); a 5 to 10 percent increase in patient visit volume (depending on how much time the doctor reinvests); a 25 percent increase in coding accuracy; and an 80 percent reduction in after-hours use. IKS Health officials also said that more than 98 percent of all patients have approved of the recording after explanation. 

Jones says that in her practice, the patient approval rate is actually higher than 98 percent. She notes that the EHR she has at USMD is the only one she’s ever known since coming out of residency six years ago, meaning she doesn’t have much to compare it to. “But I will say that the patient experience has definitely improved now that I am not buried in my computer so much. There just aren’t enough hours in the day and we have a lot of people to take care of. The virtual scribe has helped that relationship.”

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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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