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Live from CHIME16: Banner Heath's Prosperous Story on Aligning IT and Business

November 3, 2016
by Rajiv Leventhal
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A business plus IT partnership model has driven increased organizational success at Banner Health

It was a little more than three years ago when Ryan Smith was interviewing for a senior level IT position at Banner Health, the Phoenix, Ariz.-based integrated health system, one of the largest of its kind in the U.S. At that time, Smith said there was one common thread to his 12 different 1-on-1 interviews with the executive leadership team at Banner: the senior executives said that traditionally, the IT department had been difficult to work with, had its own processes, and did its own planning.

As such, Smith, who got the job and is now senior vice president of IT and CIO at Banner Health, knew there had to be  more of an emphasis on aligning business and IT—a pain point across many healthcare organizations today. Smith told the story of how Banner Health has been able to create a business plus IT partnership model that has driven increased organizational success at the College of Healthcare Information Management Executives (CHIME) CIO Fall Forum at the JW Marriott Phoenix Desert Ridge Resort in Phoenix.

Smith’s presentation on Nov. 3 was in front of a packed room of healthcare leader attendees, many of whom face similar challenges as Smith did at Banner. What’s more, Smith noted that when he took the job, he was told that there wasn’t any major merger and acquisition (M&A) activity forthcoming, thus limiting the “craziness” from an IT standpoint for a new CIO. Lo and behold, within 30 days of Smith joining the health system, it closed a deal with a small community hospital, with many more academic medical centers and other hospitals being acquired since then. “It has never stopped; this week alone we announced a joined venture with Aetna, and we also acquired 32 urgent care clinics,” Smith said.

So, the job proved even more challenging than Smith imagined. Here, he pointed to three critical success factors: Banner's operating model; the business/IT partnership; and Banner's planning process. The operating model was the biggest part, Smith said. It consists of a single board of directors that governs all of Banner, meaning attentions and loyalties aren’t split up in different directions. And, there are centralized corporate functions. “It’s designed to achieve results,” Smith said. “The work has changed in healthcare, so taking out unneeded waste and cost was key for us, as well as improving patient and member experiences. There is great alignment at Banner [regarding] how we think about strategies from senior leaders and board members. And with that, comes great opportunity,” he said.

To this end, Smith said it became clear that this organization was driving and leading too many of the technology projects. “Isn't that what we do as IT leaders?” he asked rhetorically. “Not necessarily,” he answered.  “We're a key stakeholder in that process, absolutely, but over the last few years at Banner, we have named a strong business champion who has partnered with an IT champion. We find the right person at the right level to be that dyad partner,” Smith explained, noting how the dyad leadership model is a strong one to solve problems that could be too big for any one individual. He compared the relationship to one Batman and Robin, with the business champion being the one to take the lead. “They are co-responsible for developing and communicating strategies, planning, and strategy execution,” he said. “This dyad model is applied to each major technology initiative.”


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Smith added that whatever the case may be, a broader governance is still needed. “So we set up a business-driven IT governance structure in which the business champion typically serves as committee chairperson and the IT champion serves as the co-chair,” Smith explained. “I coach my team to let that business or clinical champion run the meeting, and be the face whenever possible. The dyad oversees the subcommittees, and it's also their responsibility to make sure key stakeholders are participating from the outset,” he said.

Putting the Operating Model into Action

Smith said the dyad model is driven by Banner's overarching operating model, and necessitates consistent, consolidated, and efficient IT services system-wide. As such, this facilitates rapid integration planning and execution processes, and allows for massive leveraging of enterprise technology investments, he said.

“So for the small community hospital we acquired, we don't have to sit down and debate every week and month how much they should look like the rest of Banner,” Smith said. “It doesn't matter what EHR (electronic health record) or network they put in, because at the end of the day, we recognize that our model requires consistency and allows us to be really fast when we think about M&A integration.” Indeed, the model: assumes ALL acquisitions will be rapidly integrated; allows for less time spent on deciding whether or not to integrate; and provides a playbook for executing all phases of IT integration efforts, he said.

The time and resources saved in this approach are invaluable, Smith added. “I don’t have to fight constantly about any organization we acquire; the debate and discussion has already occurred and agreed on up to the board level. That means we need good contracts in place and good licensing agreements, so there is a lot of homework involved. But it also allows us, from an IT perspective, to ‘Bannerize’ acquisitions quickly,” he noted.

Smith gave a few examples of this strategy being put into action on the M&A front. For one, when Banner acquired Goldfield Medical Center in Junction Ariz., the business systems and EHR were integrated 30 days post-acquisition. “And this was without ever walking into the medical center prior to the [merger],” Smith attested. Meanwhile, Casa Grande Medical Center, 20 miles south of Phoenix, had its business systems integrated over and completely done on just one single day, while the EHR integration took seven months. Smith explained that this was because Casa Grande was a Cerner customer and was progressive in Cerner's cloud and revenue cycle software, so it took time to “Bannerize” them. Finally, Payson Medical Center in Payson, Ariz., only took one day total for both its business systems and its EHR.

Smith credited these incredibly quick timeframes to Banner’s operating model. “We believe this is a very viable model. And we have advanced care management and clinical decision support processes, so while it might look vanilla, in reality, these [acquired] organizations get the best of Banner very quickly. That brings lots of intrinsic value to those sites that historically might have been underserved,” he said.

Smith was asked about getting the new clinical staff up to speed with these technology changes, to which he said Banner has a very hands-on training and shadowing staff in the weeks following the go-live. “What's key is that we need them to look like Banner quickly. Otherwise they continue to hemorrhage,” he said, adding that sometimes he can't even share with his team that Banner is acquiring a facility until 30 days before it happens. “So it can be challenging and we are scrambling at times,” he acknowledged.

Regarding data migration from older, legacy systems, Smith said there is no crisp solution to that, but the general approach is that Banner will bring forward the normal pieces from a clinical perspective, such as patients’ allergies, problems, and schedules, and migrate that data as quickly as possible so there are easy screens and processes inside Banner’s systems for when that information is needed by clinicians.  

When the dyad model was set, Smith said he immediately partnered with Banner’s CMIO, who admittedly never “felt the love from IT,” so he had felt hamstrung when it came to shaping clinical IT.  “But we sat down and came up with the concept of one patient/one health record, anywhere across the care continuum; being able to share data across all organizations [across Banner]; and having a single platform for patient engagement from a portal perspective,” Smith explained. “We co-engineered what that strategy looked like and we have delivered on it over the last few years.” He concluded, “Part of our success also is creating very strategic relationships with your core vendors, even if that means kicking vendors out who don't share your vision.”

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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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