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Leveraging Technology to Support Behavioral Healthcare Management in Michigan

June 8, 2018
by Mark Hagland
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At the Community Mental Health Center of Ottawa County in Holland, Michigan, leaders are leveraging IT to improve care management

Community Mental Health Center of Ottawa County (CMHOC), located in Holland, Michigan, is a public provider of services for people with developmental disabilities, serious mental illness, and substance use disorders. The organization is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), and offers a range of programs from five locations throughout the county.  CMHOC is one of 46 community mental health centers in the state of Michigan; it encompasses about 105 staff members, two-thirds of them clinicians, and serves 3,200 active consumers of its services every year.

CMHOC has been using an electronic health record (EHR) from the Lisle, Ill.-based Netsmart, since 2005. Like many behavioral healthcare providers, CMHOC has had to adapt to funding reductions as well as significant changes in regulations, payment models and reporting data. Rich Francisco, deputy director of CMHOC, spoke earlier this year with Healthcare Informatics Editor-in-Chief Mark Hagland, regarding the organization’s journey into automation-facilitated population health management and care management. Below are excerpts from that interview.

Tell me about the implementation and optimization of your EHR.

I came on board in 2011. The decision was made in 2005 to go to an electronic health record system, and at that point, they had switched from an old QS system to Netsmart. That’s when the decision was made to go paperless. And in 2011, when I came on board as the IT coordinator, they were on a version of Netsmart, Avatar, that had not been updated for some time. So my first order of business was to get it up to date. We skipped several versions of the software, including versions introduced in 2004 and 2006.

So there was a huge project we started with, which resulted in our decision to switch our parent module to using a practice management system. It was called the “flip project,” because we wanted to flip the two. myAvatar PM (practice management) module. We used to use MSO, which was the outward-facing provider module. Netsmart went through a thorough evaluation of how the product was being used, and that’s how we went with this.


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Rich Francisco

What were some of the key issues involved in the transition for your organization?

The biggest thing we were trying to move away from was a heavy reliance on paper. Even in 2011 when I arrived, we were still very dependent on paper; we had a project, the health information management project, which involved converting our forms from paper to electronic, into the EHR. We’re talking about hundreds of forms, from assessments to tracking forms.

What kinds of efficiencies and benefits have you and your colleagues obtained in from getting away from paper in behavioral healthcare?

The biggest savings we achieved was achieving immediate access to information, and being able to analyze a lot of the data right away, and being able to report off it and analyze it, that’s one of the biggest values. We’re just getting to the point now where we’re beginning to be able to develop profiles of consumers in the system. And because we’re capturing all that data in the EHR, we’re able to develop a single view of a patient. And we’re able to track our costs through the system. We look at outliers through utilization management. And without going electronic, we could never have done this well.

But now, we’re able to run a good utilization management committee, in which we’re able to look at utilization and cost data, and benchmark our performance against the performance of peer community health centers, and that allows us to make decisions regarding practice. The fact is that behavioral healthcare has been years behind physical healthcare in digitization, because we didn’t have the incentives coming out of the meaningful use program.

So you’re trying to catch up, and do good population health and care management?

Yes, that’s absolutely right. Back in 2011, one of the first things I did was to sign a contract with Netsmart to pursue meaningful use. In the early stages, we were making sure we had all the elements in the EHR that would allow us to participate and get the incentives. So we had registered five prescribers in the 2011-2012 period, when we started the process of evaluation. We made sure to evaluate all aspects of the solution, from security issues, to making sure all of our prescribers, including our doctors, were registered.

I saw the value in it, because, first of all, we could shore up our EHR. And I said, we need to do this now, we need to invest in the product now, to make sure we’re compliant. And that was a good decision, because we’re able to report the data we need to report.

How many of your clinicians were eligible for meaningful use?

We have three who are registered—two nurse practitioners, and a psychiatrist.

Was it difficult to get them certified for meaningful use?

The product that we’re using had all the components. What was hard was the registration of prescribers. We had one who was already registered at a different agency, so we couldn’t claim them. Also during that time, we had registered agency-wide for meaningful use; so how did we get them to sign the funds over to us? Because we signed up as an agency, not as individuals, per the eligible professionals. That was the hard part.

So your EPs have received some funding from the meaningful use program?

Yes, that’s correct.

What have been the biggest lessons learned so far on this journey?

I would say it’s knowing your costs. It’s always been very difficult in BH to know your true costs. We’re operating off this historical model of basing funding on what it was in the previous year. Now, with everything accessible in the EHR, we’re able to leverage data in utilization management, to determine our costs. Is it at the level we should be, or over- and under-utilizing? Now, we have reports that tell us.

Have you been sharing data with any other community behavioral health centers in Michigan?

Yes, we’ve been participating with the Michigan Health Information Network (the East Lansing-based statewide health information network); we’re in the testing phases of getting admissions, discharge, and transfer data. That’s going right into the care record; and it would alert us to admissions, discharges and transfers, for our patients. It’s a one-way communication; they feed us the ADTs [admission, discharge, and transfer data].

And in the state of Michigan, we’re broken into regions. And we have five community health centers within our region; we’re one of five. And we’re exchanging data. Our data goes up to the regional entity, and we utilize another product for analytics, on that regional level.

What should healthcare IT leaders from any organization that you might collaborate with, know?

The biggest thing for me is to be able to share records with an agency that needs it, in the case of a transfer of care, or our provider network knowing that they’re entering physical health or being transferred to another care provider, being able to share that data. So from our local inpatient hospital here—let’s say one of our consumers presented at the ER; they should have our records in the ER. And there’s some effort taking place at the state level now, with that. But that should also be taking place at the local level.

What’s next for you and your colleagues, in all this?

For me, it’s really shoring up our outcomes basis and value basis. We’d like to become more standardized in terms of our local efforts. I’d really like to be able to have a standardized recommendation for level of care, that comes out of the ANSA—the Adult Needs and Strengths Assessment—[the a multi-purpose tool developed for adult’s behavioral health services to support decisionmaking, including level of care and service planning, to facilitate quality improvement initiatives, and to allow for the monitoring of outcomes of services]. I’d like to be able to have a standardized output for level of care, out of that assessment, utilizing data. We’re also evaluating other tools for other assessments as well. These assessments might be for substance abuse; might be for the assessment of children. The next step would be to come up with an appropriate level of care, using these standardized assessments, and then to develop a standardized recommendation. But the algorithms need to be built in.

Given the kind of progress that you and your colleagues at CMHOC are making, how fast will such progress be evolving forward across the U.S. healthcare system, in the next few years?

All of our partners have rolled out the ANSA in some fashion. We rolled out the ANSA for our organization, in the past year. And the region has hired Integrated Health Analytics, it’s a PhD statistician with a couple of master’s-level statisticians, to produce the algorithms we need to determine level of care. We should have a standardized protocol for recommendations for next level of care, out of that. In Michigan, it’s all recommendations, because it’s delivered for patient-centered planning.




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Research: Physician Burnout is a Public Health Crisis; Improving EHR Usability is Critical

January 18, 2019
by Heather Landi, Associate Editor
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Physician burnout is a public health crisis and addressing the problem requires improving electronic health record (EHR) standards with a strong focus on usability and open application programming interfaces (APIs), according to a new report from leading healthcare researchers.

The report is a “call to action,” the researchers wrote, “to begin to turn the tide before the consequences grow still more severe.” The researchers also recommend “systemic and institutional reforms” that are critical to mitigating the prevalence of burnout.

The result of collaboration between researchers with the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T. H. Chan School of Public Health, and the Harvard Global Health Institute, the report's aim is to inform and enable physicians and health care leaders to assess the magnitude of the challenge presented by physician burnout in their work and organizations, and to take appropriate measures to address the challenge, the researchers say.

The report also offers recommended actions for healthcare leaders to take, which the researchers acknowledge are not exhaustive, but “represent short-, medium-, and long-term interventions with the potential for significant impact as standalone interventions.”

The authors of the report include Ashish K. Jha, M.D., the K.T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health, and director of the Harvard Global Health Institute; Andrew Iliff, lead writer and program manager, Harvard Global Health Institute; Alain Chaoui, M.D., president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration, Massachusetts Health and Hospital Association; Maryanne Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael Miller, director, practice solutions and medical economics, Massachusetts Medical Society.

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession, according to the report.

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000-$1,000.000. 

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” Dr. Jha, a VA physician and Harvard faculty member, said in a statement in a press release accompanying the report. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

The beginning of the physician burnout crisis can be traced back to several events, according to the researchers, including the “meaningful use” of electronic health records, “which transformed the practice of many physicians, and was mandated as part of the 2009 American Reinvestment and Recovery Act.” Going back further, the 1999 publication of the Institute of Medicine’s “To Err is Human” highlighted the prevalence of medical errors, brought new attention to quality improvement and the value of physician reporting and accountability, the report states.

The researchers note that the primary impact of burnout is on physicians’ mental health, “but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public,” the researchers wrote.

The researchers note, “If we do not immediately take effective steps to reduce burnout, not only will physicians’ work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe.”

And, while individual physicians can take steps to better cope with work stress and hold at bay the symptoms of burnout, “meaningful steps to address the crisis and its root causes must be taken at a systemic and institutional level,” the researchers wrote.

According to the researchers, the primary drivers of physician burnout are structural features of current medical practice. “Only structural solutions — those that better align the work of physicians with their mission — will have significant and durable impact,” the researchers wrote in the report.

To that end, the researchers’ immediate recommendation is for healthcare institutions to improve access to and expand health services for physicians, including mental health services.

In the medium term, technology can play a large role. Addressing physician burnout will require “significant” changes to the usability of EHRs, the researchers wrote, including reform of certification standards by the federal government; improved interoperability; the use of application programming interfaces (APIs) by vendors; dramatically increased physician engagement in the design, implementation and customization of EHRs; and an ongoing commitment to reducing the burden of documentation and measurement placed on physicians by payers and health care organizations.

New EHR standards from the Office of the National Coordinator for Health IT (ONC) that address the usability and workflow concerns of physicians are long overdue, the researchers state. One promising solution would be to permit software developers to develop a range of apps that can operate with most, if not all, certified EHR systems, according to the report. The 21st Century Cures Act of 2016 mandates the use of open APIs, which standardize programming interactions, allowing third parties to develop apps that can work with any EHR with “no special effort.” There already have been efforts on this front, such as Epic’s “App Orchard,” the researchers note, but more work remains to be done.

To expedite this critical process of improvement, the report recommends physicians, practices, and larger health care delivery organizations, when seeking to purchase or renew contracts for health IT, adopt common RFP language specifying and requiring inclusion of a uniform health care API.

The researchers also say that artificial intelligence (AI) can play a promising role as AI technologies can support clinical documentation and quality measurement activities.

Long term, healthcare institutions need to appoint executive-level chief wellness officers who will be tasked with studying and assessing physician burnout. Chief wellness officers also can consult physicians to design, implement and continually improve interventions to reduce burnout, the researchers wrote.

“The fundamental challenge issued in this report is to health care institutions of all sizes to take action on physician burnout. The three recommendations advanced here should all be implemented as a matter of urgency and will yield benefits in the short, medium, and long term,” Jha and the research team wrote.


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GAO Report: Patient Matching Efforts Can Be Significantly Improved

January 17, 2019
by Rajiv Leventhal, Managing Editor
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The report did conclude that no single effort would solve the challenge of patient record matching

There is a lot that can be done—such as implementing common standards for recording demographic data—to improve patient matching, according to a new Government Accountability Office (GAO) report that closely examined the issue.

The 21st Century Cures Act included a provision for GAO to study patient record matching, and in this report, GAO describes (1) stakeholders' patient record matching approaches and related challenges; and (2) efforts to improve patient record matching identified by stakeholders.

The 37 stakeholders that GAO interviewed, including representatives from physician practices and hospitals, described their approaches for matching patients' records—comparing patient information in different health records to determine if the records refer to the same patient.

The respondents explained that when exchanging health information with other providers, they match patients' medical records using demographic information, such as the patient's name, date of birth, or sex. This record matching can be done manually or automatically. For example, several provider representatives said that they rely on software that automatically matches records based on the records' demographic information when receiving medical records electronically.

Stakeholders further said that software can also identify potential matches, which staff then manually review to determine whether the records correspond to the same patient. They said that inaccurate, incomplete, or inconsistently formatted demographic information in patients' records can pose challenges to accurate matching. For example, records don't always contain correct information (e.g., a patient may provide a nickname rather than a legal name) and that health IT systems and providers use different formats for key information such as names that contain hyphens.

Those who GAO interviewed identified recent or ongoing efforts to improve the data and methods used in patient record matching, such as the following:

  • ·         Several stakeholders told GAO they worked to improve the consistency with which they format demographic data in their electronic health records (EHR). In 2017, 23 providers in Texas implemented standards for how staff record patients' names, addresses, and other data. Representatives from three hospitals said this increased their ability to match patients' medical records automatically. For example, one hospital's representatives said they had seen a significant decrease in the need to manually review records that do not match automatically.
  • ·         Stakeholders also described efforts to assess and improve the effectiveness of methods used to match patient records. For example, in 2017 the Office of the National Coordinator for Health Information Technology (ONC) hosted a competition for participants to create an algorithm that most accurately matched patient records. ONC selected six winning submissions and plans to report on their analysis of the competition's data.

Those who were interviewed said more could be done to improve patient record matching, and identified several efforts that could improve matching. For example, some said that implementing common standards for recording demographic data; sharing best practices and other resources; and developing a public-private collaboration effort could each improve matching.

Stakeholders' views varied on the roles ONC and others should play in these efforts and the extent to which the efforts would improve matching. For example, some said that ONC could require demographic data standards as part of its responsibility for certifying EHR systems, while other stakeholders said that ONC could facilitate the voluntary adoption of such standards. Multiple stakeholders emphasized that no single effort would solve the challenge of patient record matching.

To this end, a recent report from the Pew Charitable Trusts outlined several key themes related to patient matching, while also suggesting recommendations to improve matching and the infrastructure needed for more robust progress in the medium and long term.

Related Insights For: EHR


Montana Senator to VA CIO: “EHR Modernization Cannot Fail”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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Senate VA (Department of Veterans Affairs) Committee Ranking Member Jon Tester has urged new VA CIO James Gfrerer to avoid past failures as he helps to move forward the department’s EHR (electronic health record) modernization project.

Gfrerer, an ex-marine and former executive director at Ernst & Young, was recently confirmed by the Senate to serve as assistant secretary of information and technology and CIO (chief information officer) at the Department of Veterans Affairs.

One of Gfrerer’s top tasks will be helping to update hospitals’ infrastructures as the VA continues to work on replacing the department’s 40-year-old legacy EHR system, called VistA, by adopting the same platform as the U.S. Department of Defense (DoD), a Cerner EHR system. That contract was finally signed last May and the implementation project is scheduled to span over 10 years.

In a letter to Gfrerer, Tester, a Montana senator, noted that while many of the responsibilities for the implementation of VA’s new EHR fall to the recently created Office of Electronic Health Record Management, the CIO’s role “is critical to ensure that we do not repeat the mistakes of the past.”

The office that Gfrerer now leads, VA’s Office of Information and Technology, will still be in charge of managing infrastructure needs for both the patient care facilities that have received the EHR upgrades and those that have not, Tester stated. “This task will require significant resources and robust oversight as VA manages a decade-long rollout,” he said.

Tester further wrote, “EHR modernization cannot be allowed to fail, and your leadership is essential if VA is to ultimately achieve a truly interoperable health record for veterans.”

In regard to “past failures,” it’s possible that Tester is referring to media reports that have outlined some of the significant issues that the DoD has had with its own Cerner rollouts. In reports throughout 2018, the initial feedback on the four military site EHR rollouts has been less than ideal. A Politico report first detailed the first stage of implementations noted that it “has been riddled with problems so severe they could have led to patient deaths.” Indeed, some clinicians at one of four pilot centers, Naval Station Bremerton in Washington, quit because they were terrified they might hurt patients, or even kill them, the report attested.

Providing an update on Cerner’s progress with the DoD EHR implementations, a company executive recently noted that he is seeing “measurable progress” at the DoD’s initial operational capability (IOC) sites.

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