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A Nursing Informatics Leader Parses the Challenges of EHR Optimization

May 9, 2017
by Heather Landi
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In conjunction with National Nurses Week, HIMSS’ Joyce Sensmeier, R.N., reflects on the role of nursing informatics in a post-EHR implementation era
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As more healthcare delivery organizations undergo clinical transformation processes, the demand for nurses with informatics training and expertise continues to gain momentum. In fact, a 2015 nursing informatics report by the Healthcare Information and Management Systems Society (HIMSS) found that informatics nurses were widely seen as bringing value to the use of clinical systems and technologies at their healthcare organizations. Respondents to that survey indicated that nursing informaticists bring greatest value to the implementation phase (85 percent) and optimization phase (83 percent) of clinical systems process. Informatics nurses also were viewed as having a direct positive impact on the quality of care patients receive.

In addition, the 2017 Nursing Informatics Workforce Survey conducted by HIMSS continues to suggest that nurse informaticists play a crucial role in the development, implementation, and optimization of clinical applications, including nursing clinical documentation, computerized practitioner order entry (CPOE) and electronic health records (EHRs).

In conjunction with National Nurses Week (May 6-12), Healthcare Informatics Associate Editor Heather Landi caught up with Joyce Sensmeier, R.N., vice president of informatics at HIMSS North America, to discuss the evolving and expanding role of nurse informaticists. Sensmeier shares her perspective on how nurse informaticists are uniquely positioned at the intersection of IT and patient care, making them indispensable to health systems trying to realize value from health IT investments and achieve improved outcomes.

What are some of the biggest trends that were identified in the 2017 Nursing Informatics Workforce Survey?

One of the things that jumped out at me was a change in the reporting structure. Nursing informatics has been around since the early 1990s. I was a part of that grassroots wave, leveraging nurses that had an interest in technology and using them to begin to implement EHR systems. Back then, many of us reported up through nursing, and then it seemed like there was a trend with more reporting up through IT. Now there’s still those two branches, but there’s more reporting up to corporate. So, it’s become more of an overarching role, as opposed to either siloed in nursing and IT. To me, that really speaks to a maturing of the specialty, which I’m pleased to see.


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Another trend we’re seeing is that we’re pretty much done with first wave of EHR implementations. And now, while sometimes those systems are getting replaced, upgraded, but even more so, optimized. The nurse informaticists are working more on refining the implementations and getting the workflow more aligned and more efficient using the systems. There also is a need to make sure the structure enables us to get outcomes and that can come with issues such as, how the data is recorded, or if there are standards used, and even the structure of the database and being able to finally get value out of the EHRs. So it’s not just ‘Okay now we have the EHR,’ but now it’s ‘Okay, now that we got it, what do we do with it, and how do we leverage it to really demonstrate value-based care?’

Joyce Sensmeier, R.N.

How do you see the nursing informatics role evolving?

There is an increasing awareness of the need for someone with both a clinical background as well as a technology background and with that understanding and expertise. There really is growing recognition of the specialty of the nurse informaticist and the special expertise that nurse has to really improve the systems, to refine them, to leverage them, make them more efficient. So it’s more of a maturing of the specialty; more nurses in those informatics roles are master’s prepared and they are getting certification, so they are able to demonstrate the expertise that they have gained over time in their tenure.

Have the responsibilities and requirements of nurse informaticists changed?

I would say there have been quite a few changes. In the beginning, which is, again, decades ago, back in the 1990s, it was thought that when we were implementing technology, we wanted to make sure that we had people with an understanding of the impact on patient care. So that’s why nurses were really recruited into roles that they weren’t necessarily equipped for, and I’ll include myself in that. So we had to learn on the job and grab information wherever we could and really begin to network with each other to learn how to do that in an optimal way. So here we are 2017 and what we saw in our survey was that the nurses are much more educated as there are informatics programs throughout the country, master’s levels and doctorate level and beyond. Also, the specialty is not just hospital-centric; nurses are working in informatics in academia and research and policy. So, there is a maturing of the roles that the informatics nurse can play. Also, there are certification programs for a specialty in nursing informatics and more nurses are seeking certification.

The other important thing is, in the beginning I think there was this idea that nurse informaticists would be focused on nursing systems, but now that role is really being used for all types of systems. And, we saw that in the survey as well—implementing EHRs, implementing clinical systems, but also working on solving interoperability problems and doing research across informatics and working with our other clinical partners, such as physicians and pharmacists, to move the bar forward in informatics.

What role does nursing informatics play in the ongoing transition to value-based care and value-based payment?

It’s a critical role. We [HIMSS] did a survey on the impact of nurse informaticists and one of the points that was made by CIOs who responded to the survey was the idea of patient safety. They valued the role of the nurse in the IT area as the nurses have worked with patients to understand what can impact patient care in a negative way. The informatics nurses are typically tasked with doing the testing of the system, certainly the clinical systems, before they are being implemented. So they can see what triggers could cause incorrect data to be displayed or not carried over, or the care coordination being a deficit. The clinical background and also the training and education on understanding evidence-based information; that really is a part of what the nurse brings to the table. So I think that is a huge asset that is being recognized by CIOs, and even CNOs, because they are often tasked with those IT projects and they don’t have that expertise, so they are really relying on the informatics nurse for that.

You mentioned the ongoing need for EHR optimization and for healthcare provider organizations to get value out of their health IT investments. What role does nursing informatics play in a post-EHR implementation era?

The nurse has been at the bedside and understands the information needs in order to do his or her job well and that moves forward into their role to really be an advocate for that. So part of that is interoperability, the nurse needs information about the patients that he or she is working with at the point of care—at the bedside, or in the ambulatory clinic or in the ER when patients arrive. That’s a really important aspect of their understanding that they can bring in to the dialogue that they have with systems implementations.

With regard to value-based care, if we are moving into a time where we’re going to be getting reimbursement based on the value of the care we provide and making sure that the right care is given at the right time, that depends on the systems being structured in a way to be able to get that information out of the systems. So, if you have your EHRs in place, but you don’t have it set up with standards to make sure that the data is consistent across your system, you’re not going to be able to see what makes a difference in the outcomes of your care; it’s dependent on the structure of the system. For informatics nurses, that is a part of our training—the design and systems analysis components as well as an understanding of the standards that enables the interoperability of that. The bottom line: if the data is not structured right, you’re not going to be able to see the outcomes at the end of it. You have big data, you have a lot of data, but if you’re not able to consistently see the same data in the same way at the end, you’re not going to be able to do that analysis.

So, moving forward, it’s not just about the technology, but what the technology enables?

It’s all about the patient, and the benefits of having data at the right place and the right time, having clinical decision support that is accurate and timely, and being able to improve the outcomes of your care—that is what technology can do, if it’s implemented in the right way and used in the right way, and if you have experts focused on helping to make that happen. If the hospitals and health systems make that investment it’s going to come back in spades. Because, ideally, you would see fewer patients getting readmitted within a short period of time, and the patients would have the ability to see their health information, understand it and to take ownership of it to improve their health. So it builds more of an environment that is full of information that can be leveraged and used rather than just a bunch of data that’s in a back room and in files, like it used to be.

What I also see happening is more of an inter-professional approach because all the clinicians, physicians, nurses and respiratory therapists have access to the information in what we used to call the charts, so now it’s the health record. As a result, we have a better understanding of what the other specialties are doing with the patient and how we interconnect. So, it’s less likely that we’re having a siloed approach and we can really have a shared approach with the patient that is inter-professional and respecting across the specialties. However, the negative side of that is the technology can get in the way—if you’re spending too much time, if it’s not useable, if you’re not able to have the communication that’s needed, if the interoperability is not there—that can be a barrier.

What should healthcare provider organization leaders be focused on to evolve forward into this post-EHR implementation era?

This new era cannot be realized with technology alone; it requires equal parts data and patient perspectives. They should be thinking about wanting to make sure their systems are able to demonstrate outcomes and that they have the clinical integration that they need to do so. We’re no longer able to rely on acute care data. We really need that coordination of care because as individuals are using your system, you want to support them through that whole lifecycle of health. So if they are in the home and they are active and healthy, they might be using fitness trackers and there could be some data that’s available there. So when an individual comes in, they have patient-generated data to consider as well so that the patient is part of the conversation along the way. I think they need to consider capturing that data in a way that you can see it all through that continuum of care, and access it and act on it appropriately.

Broadly speaking, across the healthcare industry, what do you see as the timing for this evolution?

Some of this is going to depend on the current Administration and where we’re heading. Certainly, a year ago, with value-based care being very much talked about and held up as a model and an idea of a learning health system, I would have said that it would come a little sooner. There was an idea of healthcare transformation, that it was needed and we were all marching to that, and now there is just more uncertainty, given the current climate. We have certainly made progress in interoperability, and we have a ways to go yet, but that’s going to be a great driver, once we have access to data whenever we need to and in the right format. That’s going to move the bar forward more quickly. My ballpark would be five years, but I’ve been in this industry long enough to know that things can change.


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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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