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In Northern California, Leaders at One FQHC Leveraged Technology to Help a Community in Crisis

June 4, 2018
by Heather Landi
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In early October 2017, wildfires ravaged Northern California communities, destroying homes and businesses, displacing residents and resulted in the deaths of at least 43 people. All told, the October wildfires burned more than 245,000 acres in Northern California and forced 20,000 people to evacuate.

According to local news reports, on Oct. 8 and into Oct. 9, small fires fueled by extreme winds merged into six massive fires, with the biggest fires in Sonoma and Napa counties. The most deadly and destructive of the fires was the Tubbs Fire in Santa Rosa, and it took 23 days before the wildfires were contained. During the wildfires, two out of three hospitals in Santa Rosa, as well as many other medical facilities, were forced to evacuate patients and could not resume medical services.

A building destroyed in Sonoma County

Just 17 miles south of Santa Rosa, Petaluma Health Center, a federally qualified health center (FQHC), remained open and served as a safe haven for the local community, providing ongoing medical services to those in need. Leveraging a number of technology tools, Petaluma Health Center providers were able to quickly and effectively communicate with patients during the crisis and provide quality patient care, even to evacuees housed at a dozen local shelters, throughout the disaster.

“It was a Sunday night when the fires began, coming across from Calistoga over the mountains to Santa Rosa, and in the middle of the night people were started to be evacuated and the fires were quickly approaching two of the three major hospitals in Santa Rosa. So, even from the middle of the night, we knew there would be a big impact in terms of people being able to access care,” says Danielle Oryn, D.O., chief medical informatics officer at Petaluma Health Center, and a family physician.

Petaluma Health Center provides health care services to 35,000 patients in Sonoma County each year and was a recipient of the 2017 Community Health HIMSS (Healthcare Information Management and Systems Society) Davies Award for its use of electronic health record (EHR) analytics to improve health outcomes.

“As a FQHC, we do have a focus on serving the underserved and we focus on serving the entire community. About half of our patients are non-English speakers, and a good percentage of our patients are at the 200 percent of federal poverty level or below. So, we’re a typical community health center, and we have two big sites, one in Petaluma and another one in Rohnert Park and smaller sites, one at a homeless shelter and a couple of school-based health centers,” she says.

Oryn and her team of physicians knew that there would be both short-term and long-term healthcare needs as a result of the wildfires and the resulting smoke. From asthma and hypertension to the straining of evacuating and rebuilding, thousands needed medical and psychological help.

“With two hospitals being closed and much of the outpatient care in Santa Rosa, including Kaiser and many of the health centers and private offices, being closed, people would need healthcare, whether they needed refills because they were evacuated from their homes and didn’t get to bring everything that they needed, or simply because of the heavy smoke in the air,” Oryn says.

While the Rohnert Park site had to close for two days, the Petaluma site remained open to provide outpatient care. “We were ready to receive patients, but we needed to get the word out to the community that we were here, we were open,” she says, crediting many of the features and tools within the health center’s eClincalWorks EHR system with facilitating effective communication. Using a tool within the EHR, Petaluma Health Center staff were able to send out messages to 50,000 patients in its database with a message informing them that the health center was open and capable of providing medical care.

“What we noticed after that is that people were posting on social media, saying, ‘I just got a text message from Petaluma Health Center, they’re open, if anybody needs care, go there.’ So it had a ripple effect, which was really important to our community, to be able to get the word out that we have staff and are able to take care of patients,” she says.

Danielle Oryn, D.O.

The health center’s waiting room soon filled up, mostly with patients in need of medication refills. Armed with iPads, providers went out to the waiting room and utilized a feature within the eClinicalWorks EHR to refill prescriptions on the spot.

“As a direct effect of the fire, we saw a lot of people with exacerbation of asthma, respiratory complaints, irritation from smoke in way or another. We also saw a lot of people who were temporarily, or even potentially permanently, displaced from their homes, and they had to leave their houses in a hurry and didn’t take much with them. So, we saw a lot of people who simply needed medication refills and to be reconnected to some kind of primary care for a temporary time period,” Oryn says.

Petaluma Health Center clinicians also leveraged a local health information exchange (HIE) operated by the Redwood Community Health Coalition to access patients’ health records from other health centers. The RCHC’s Redwood Community HIE is a private query-based HIE hub that facilitates health center access to data sharing. Currently, eight RCHC health centers populate records into RCHIE, which contains close to 200,000 continuity of care records.

“The private HIE connects all the community health centers throughout the region, and so we were able to access records from the health center that was damaged and closed, and we were able to access prescription records from SureScripts. I can look up at a patient within the EHR at Petaluma Health Center and bring in parts of that record or view parts of that records and that enables me to provide continued primary care,” Oryn says, “We were really able to maximize use of all those tools in order to take care of this influx of people from outside our normal area.”

At the same time that physicians on-site at the Petaluma Health Center were treating patients, clinicians also went out to local emergency shelters, of which about a dozen were set up during the crisis, to take care of patients who may have been evacuated from long-term care facilities or hospitals. “We were trying to help to take care of whoever we could, so that the emergency rooms would be a little less impacted,” she says

Another health center in the East Bay loaned Petaluma staff a medical van so providers were able to get out into the community to provide medical services.

“We took our laptops and our hotspots on to that van and were able to go out and provide care, such as flu shots to first responders and people who were in shelters. We used our EHR to help provide that care working from that van,” Oryn says, adding, “For the physicians working out in the shelters, the one thing that was really beneficial was using the provider portal associated with our HIE. Providers at the shelters were accessing a couple of different portals; we were able to see one for the hospital system in order to see the hospital records and then another portal for our system to view primary care records and understand patients’ chronic medical conditions, medications and allergies.”

As people across the community were scattered in those first few days and even the first week, Oryn credits Petaluma Health Center as being instrumental in setting up a more coordinated approach to ensure people were getting care during a stressful and anxious time. What’s more, technology and health IT tools played a crucial role in enabling Petaluma Health Center providers to respond quickly and efficiently.

“The experience definitely underscored the importance being connected and interoperability,” Oryn notes. “I think often HIE in the outpatient world is a back burner-kind of issue or project, not for those of us who work in IT, but for clinical people, generally. I think having this experience of a disaster, it really led to a greater understanding of how beneficial being connected and interoperability really is. It brings up the question of, ‘Wouldn’t it have been even better had we been connected to those private doctors as well?’”

For five weeks after the wildfires, the health center saw a spike in patient visits due other healthcare facilities being closed.

“Now that operations have resumed and people are able to resume care at their primary care medical home, we still know there’s going to be longer-term impacts to health and healthcare from the wildfires; the trauma from people losing housing and the trauma from experiencing the wildfire,” Oryn says. “At this point, we’re all trying to look at ways to increase behavioral health services that health centers provide to be there and be ready for the community.”

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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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