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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.


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“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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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.

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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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