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NorthShore Integrates Pharmacogenomic Alerts Into Clinician Work Flow

February 6, 2017
by David Raths
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Health system partners with ActX on web service CDS alerts
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If you think you have trouble fitting your message into 140 characters for a Tweet, imagine trying to keep a pharmacogenomics alert to fewer than 15 words. That is the challenge Mark Dunnenberger, M.D., faces at NorthShore University HealthSystem. “We have been told that any more than that is too much for a clinician to read while they have a patient in front of them,” he said.

Dunnenberger is senior clinical specialist in pharmacogenomics in the Center for Molecular Medicine at Evanston, Ill.-based NorthShore, an integrated system with four hospitals and 2,100 affiliated physicians. In a recent interview with Healthcare Informatics, he described some of the challenges all healthcare systems face integrating genomic data into EHRs as well as how NorthShore has approached integrating pharmacogenomics alerts into clinician work flow.

Dunnenberger said most large integrated health systems are struggling with the multi-faceted challenge of getting complex genomic data into formats that clinicians can understand in an intuitive manner so they can integrate it into their current decision-making process.

“Genomic data only makes sense for a patient and patient care when put in context of everything else,” he said. “If we are really going to get implementation of personalized medicine or genomic medicine into practice, we can’t be taking the clinician out of their normal work flow, making them think about this data in a different way through a different process and then bring them back into their current work flow. That is just not going to work. Either they are going to make the wrong decision because they don’t have all the data in front of them or ignore it because it is outside their normal work flow.”

He added that harmonizing data standards of laboratory information systems and EHRs is another problem, along with figuring out how much data to send across. The amount of data you generate in a laboratory system is very different than the amount you would deliver to a clinician. “I have a feeling if I were to give them all the data I had, their eyes would glaze over,” he said.


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In many health systems today, a lab report with genomic results comes to the clinician in PDF form, which is a big problem.  “There is a tab in the medical record where scanned documents go and that might as well be a black hole because it is very hard to navigate through there and find anything you want, especially if it is something that was done a couple of years ago,” Dunnenberger explained. 

With his area, specialty pharmacogenomics outside the realm of cancer, the data collected at any point in the patient’s life is applicable at every point after that. “Imagine you had a laboratory test done five years ago. Now you are seeing a new clinician, and that data point could be really important to your care, and that new clinician has to know that the test was done, where to find it, and know what to do with it. We can’t rely on PDFs for that,” he added. “Instead, if we can get this data into the record discretely and build tools around it, we can then deliver it to the clinician with the right amount of information at just the right time. They may never have known you had that testing done five years ago; it is just delivered to them in a nice little package.”

Partnering with ActX and Customizing Alerts

To deliver its clinicians actionable alerts about pharmacogenomics, NorthShore initially tried to use the native rules engine in its Epic EHR. “What we found was to deliver the amount of complexity and detail we wanted to, it was going to be cumbersome and almost impossible to do it in that system,” Dunnenberger said. “It would have been possible, but doing it that way would require a lot of resources.”

Instead, the health system partnered with a company called ActX that provides a service that enables real-time checking of each prescription against the patient’s genetics. “They give us the framework to build the rules and logic for how to present this data in an actionable way to clinicians,” Dunnenberger said. “A lot of EHRs have interruptive alert systems with rules behind it. ActX gives us a logic engine designed to deal with genomic data. We send them the patient results and the genetic variance; we use their rules engine and customize it. It operates via a simple web service and API callout to their server any time an order is placed for a high-risk medication that has a link to pharmacogenomics, where you would want to make some change to therapy.”

 The system calls out to ActX, which send back an answer that is an interruptive alert that pops up in the clinician’s work flow just like a drug-drug interaction alert would. NorthShore has access to a pharmacogenomics profile — a list of medications that are a problem for a patient: what the problem is, how to get around it, and what the genetics are. “The beauty of this list is that it is updatable all the time,” Dunnenberger said. “Every time a clinician clicks on it, they get the most up-to-date information as we put it in the system. We are getting away from that PDF, which is a snapshot in time, to a dynamic list. If we learn something new about a genetic variation you have, the clinician gets that information and is not stuck with what we knew a year ago. The cherry on top is that it is embedded in our EHR. All a clinician has to do is click where they would click to see a lab result, and it pops up. They don't’ have to log into a different system or close the EHR. It is right there and is starting to get embedded into their work flow.”

This process does require NorthShore to maintain that knowledge base: ActX can do it to some degree, but Dunnenberger said that to hone in on what clinicians want to see at NorthShore, customization is required. For instance, both cardiologists and neurologists could be alerted on one particular drug-gene pair, depending on the indication. But the strongest data so far is with cardiology. “Our neurologists don’t want to see those alerts, so we have had to go in and customize the alerts to state that they are not preferred by neurology or limit it so it doesn’t trigger for neurologists,” he said.

 NorthShore has doing pharmacogenomics in clinical care since March 2015 and has been using the ActX system since September 2016. This has allowed it to take the ordering of genomic testing out of the pharmacogenomics clinic and put it into the hands of clinicians. “We targeted primary care physicians at the beginning so that has allowed us to exponentially grow the impact of pharmacogenomics,” he said.

“Previously, when all we had were the PDF files to send to providers, we weren’t sure they would be able to get the full context and incorporate the results,” Dunnenberger explained. So they would have patients visit the pharmacogenomics clinic for both education about risks, benefits and limitations of testing and the actual testing and sharing of results.  “Now we have it set up so the primary care provider has the tools at their disposal. We can deliver results to the clinician in their EHR. Patients no longer have to come to our clinic; however, they may want to come and get a deeper dive into what the data means, but that is up to the patient.”

NorthShore has worked to get the clinical decision support alert distilled to less than 15 words. They get a 15-word alert, then a button that says click for more information. If they click on that, they get a two-minute summary and references to go further from there if they want even more information. “We are really trying to meet their needs and it is not clear what those needs are,” Dunnenberger said.  We are taking an iterative approach. We build something, test it, see how it works, get that feedback and improve, and get it back out there.”

Looking to the future, Dunnenberger said that how and what data his clinic provides to clinicians is always going to be evolving. “We have to be nimble in creating new solutions to get this in the hands of clinicians in ways that are intuitive for them to use. Also, we are good at looking at one gene at a time but the reality is there are multiple genes at a time that we have to evaluate to make a recommendation. We have to figure out how to do that and put it in the context of care.”

Dunnenberger said he realizes that genomic data is new and that it can be scary. “But the ways you apply it to care are no different than the other clinical factors you are already evaluating,” he said. It is just more information to help make better therapeutic decisions. It is there to help clinicians, not create new therapeutic dilemmas. As long as we can deliver it in a way that is helping them, I think we are going to have real success delivering personalized or precision medicine.”


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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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