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Innovator Award Runner-Up Lakeland Health Targets Hemorrhage Risk in Labor and Delivery

February 18, 2017
by Heather Landi
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As the top two preventable causes of maternal morbidity and mortality are hemorrhage and preeclampsia, the St. Joseph, Michigan-based Lakeland Health set its sights on designing custom electronic health record (EHR) tools to assist in the assessment and prevention of these conditions.

Lakeland Health has applied EHR technologies within its obstetrics (OB) department at all three of its hospitals to support care providers in identifying warning symptoms in a timely manner to avoid costly complications. As a result of this clinical informatics initiative, Lakeland Health has optimized the usage of necessary blood supply as needed by new mothers. Before implementation in January 2015, the OB department used 37 units per 1,000 patients. In May 2016, the department used 24.8 units per 1,000 patients.

Additionally, the project leaders have reported improvements in caring for obstetric patients with regard to preeclampsia. As of May 2016, 82 percent of obstetric patients had a completed hemorrhage risk assessment and with 98 percent of patients had blood pressure taken within 15 minutes of arrival and, of those with elevated blood pressure, care providers were notified 100 percent of the time upon the patient’s arrival.

A community-owned health system, Lakeland Health includes three hospitals, an outpatient surgery center, a regional cancer center, rehabilitation centers, two long-term care residences, home care and hospice services, and 34 affiliate physician practice locations. The Lakeland Health team’s work to improve maternal health was worthy of semifinalist status in Healthcare Informatics’ 2017 Innovator Awards Program.

Robin Sarkar, Ph.D., Lakeland Health CIO, says, “One of the underlying reasons why we choose this project is that patient safety is a number one priority at Lakeland, well above everything else. Of course, we’re interested in getting the best outcomes for patients, but right at the top is patient safety.”

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Lakeland Health Innovator team: Front row: Jodi Lute, RN, Tammy Jerz, RN, Merline Abraham, RN; Back row: Cherie File, RN, Karen Yech, RN, Holly Schewe, Lynell De Wind

 

In the Innovator Awards submission, Sarkar wrote that the initiative to improve obstetric patient care is an example of a creative and innovative application of technology to solve a complex problem. “In this case, innovation is seen in the multi-incremental enhancements that have made impacts in patient safety and outcomes. The individual tools, may have had less significant impact, but the cumulative effect was significant,” he wrote. “The clinical team had a vision to improve the care for the obstetric patient. The IT/EHR analyst team took that vision and developed creative ways of building, modifying, and enhancing the EHR to provide the tools needed to improve the patient experience.”

According to the Lakeland Health project team, research shows that obstetric (OB) hemorrhage is one of the leading causes for maternal death, and a major contributor to maternal morbidity. Deaths from hemorrhage consistently rank as one of the most preventable causes of mortality with 70-92 percent of deaths judged avoidable. Several regulatory agencies identified the prevention of obstetrical hemorrhage as a priority to improve patient outcomes. Therefore, Lakeland Health participated with the Michigan Hospital Association (MHA) Keystone Initiative to innovatively utilize the EHR to support best practices and reduce the risks for morbidity and mortality.

Two years ago, clinical leaders began collaboratively working with IT staff and EHR analysts on efforts that included validating workflows and patient flows as well as technology system build and testing. The result, according to Tammy Jerz, R.N., Lakeland Health’s manager patient care services, outpatient, has been the development of tools to both meet and exceed clinical expectations. “These efforts stitch together multiple strings of data, process and protocols to give care providers the right information, at the right time, helping them make the right decision, to ensure perfect patient care, the first time,” she says.

Deeply involved in the project were a team of Lakeland Health nursing leaders and IT/EHR analysts, including Jerz; Cherie File, R.N., EHR senior analyst; Jodi Lute, R.N., EHR analyst; Marline Abraham, R.N., Karen Yech, R.N. and EHR managers Holly Schewe and Lynell De Wind. Sarkar also was involved as an executive IT leader.

And while this has been a technology-driven clinical initiative, Jerz says the initial step was getting buy-in from stakeholders and educating clinical staff on using the tools. “We needed to get everyone to understand the safety initiative for what it is and how we can really impact the lives of our patients and the babies that we serve. We need to get everyone to understanding what real blood loss is as well as how we can intervene much faster to prevent those stage 2 and stage 3 hemorrhages,” she says. Jerz adds, “Minutes can save lives, and we want to be ahead of the game every chance that we get.”

Jerz also notes, “We’ve been able to prove that the interventions work with the decrease in the number of units of blood that we’re giving on average.”

Clinical and IT leaders at Lakeland Health collaborated to automate and implement the following four innovative technology initiatives to manage obstetrical hemorrhage—a hemorrhage risk assessment; standardizing Pitocin administration during the third stage of labor; a quantitative blood loss (QBL) calculator; and an OB emergency narrator hemorrhage risk assessment, which is a flowsheet built in Lakeland Health’s EHR.

Sarkar notes that a critical key to this initiative has been working with Epic, Lakeland Health’s EHR vendor, to build the necessary tools within the EHR system. “It’s important to work with your EHR vendor so that they can understand your needs and help in the collaboration of developing the tools needed,” he says.

The first step was developing the hemorrhage risk assessment in the ambulatory office that crossed over to the hospital record and this entailed transitioning nurses and clinicians from using “estimated blood loss” to “qualitative blood loss” with the implementation of a calculator specific to both outpatient and inpatient settings. The previous “estimated blood loss” process was a manual task that left room for error, File says. With the quantitative blood loss (QBL) calculator now a technology tool within the EHR, Lakeland Health has eliminated that manual process and the tool has been integrated into the nurses’ workflow.

“What you see with the quantitative blood loss calculator is more consistency in the documentation, because it’s not as subjective as with an estimated blood loss,” File says.

Documentation starts in the ambulatory offices and continues through the hospital delivery. The risk assessment is a standardized tool that promotes the assessment of the risk of hemorrhage through the continuum of care during the pregnancy by calculating the risk for hemorrhage and prompting the nurse to select the appropriate blood order for the individual patient. This ensures that blood is available for those at greatest risk for hemorrhage and is cost-effective for those at lower risk, Jerz says.

The QBL calculator that was developed has been supplemented by a new OB emergency narrator, a documentation tool in the EHR that enables the end user to perform a number of tasks while viewing the specific timeline used during codes or traumas, according to Jerz. This tool enables real-time documentation, with the same features as the established trauma narrator. Lakeland’s IT/EHR analysts customized the EHR “model narrator” to improve care during postpartum hemorrhages. This narrator tools allows for more rapid administration and documentation of medications, with “one step functionality” and blood products during OB emergencies, Jerz says.

“Our physicians are able to pull the data from the OB emergency narrator into their documentation. This optimization has allowed our team to recognize risk from the mother’s prenatal experience and prepares providers for potential issues during delivery and recovery,” she says.

Additionally, as part of this initiative, the project team collaborated and revised relevant order sets to include standard Pitocin orders to ensure the medication is readily available for administration.

As part of this clinical informatics initiative, project leaders have found that process improvement reports and dashboards have been key elements for process improvement. Care providers stay informed of current patient status and quality metrics with the goal of providing safe and effective obstetrical care. Additionally, the report cards and dashboards show progress towards goals and are reviewed at monthly meetings and shared with all providers, nursing leadership, and staff.

Sarkar points out that the initiative was what he referred to as a “zero cost project.” “There was no incremental dollars from my IT budget or any clinical budget. This was just clinical partners under Tammy and her team stepping up and our EHR team working collaboratively and executing this project,” he says.

Critical to the success of this type of clinical informatics initiative, Sarkar says, is assimilating high-performance teams, both clinically and technically, as well as gaining management support for the organization’s IT initiatives. “Lakeland is fortunate to have very strong and supportive management across the organization, recognizing the efforts needed to provide perfect patient care. They are innovative, encouraging, and responsive, helping us succeed with positive outcomes and results,” Sarkar wrote in the team’s Innovator Awards submission.

 

 


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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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