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For One Solo Doc Practice, a Fearless IT Journey

November 21, 2016
by Rajiv Leventhal
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In 2008, Allison Blazek, M.D., made a bold career move, going from working in the emergency room at MD Anderson Cancer Center in Houston, Texas to starting a unique internal medicine solo practice just a few miles from downtown Houston, but with a small town feel nonetheless. With that career jump for Blazek came an array of new challenges that simply wouldn’t exist if she stayed at MD Anderson. She had to learn on the fly how to manage her own practice and incorporate technology to meet healthcare’s changing dynamics. At that time, one thing for Blazek became crystal clear: it was time to move off paper.

Blazek says she started out at her new solo practice with just a Sony Vaio laptop that was the “center of her life.” She says she was a hospice medical director and did house calls, so she brought her laptop with her everywhere, allowing her to work remotely all the time. But still, patients’ records were on paper charts at the time, and Blazek knew that eventually she would have start looking into electronic health record (EHR) solutions.

However, this process was far from seamless. Blazek says that every time she called a vendor, she would get the workaround in terms of never being told the product’s cost. “I would be on the phone for an hour and finally the [vendor would say] that the EHR will cost me $30,000 plus more afterwards, but at the time I wasn’t making any money so I couldn’t do that.” Blazek says she figured that she would just stay on paper for the time being considering the difference in cost. But then one day, while reading a story about the poor adoption of EHRs, she came across Practice Fusion, which offers a free web-based solution. “I thought to myself, free I can do,” Blazek says.

Even after the implementation of Practice Fusion, Blazek was essentially still working on IT alone. She says she does have a friend who is an actual IT person who helps her out from time to time, but there is nothing resembling a real IT department at her practice. “I’m constantly looking up things and asking other doctors who make these decisions in private practice what they’re doing, and then I try different stuff out. I download everything and I figure it all out myself. There’s no one else here to help me,” she says.

While this level of sole responsibility might sound scary to many doctors, Blazek actually says it’s better for her since she’s the one making the decisions. For example, she notes that MD Anderson had an “amazing medical record system” that was developed by an internal radiologist, but the organization eventually decided to switch to Epic, which Blazek says has caused problems. “They had no choice in that [EHR] switch,” she says. “Here, no one has ever forced change on me that I may or may not agree with. So I think I actually have it better now,” she attests. She adds, “I would say that it has made my practice more possible. Everything is easier. I can check messages and do refills from another country. And I don’t need to have someone in my office covering for me when I am gone because I have everything with me.”


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At Blazek’s practice, there is an emphasis on treating the whole patient, thus seeing no more than 15 patients a day to allow time for comprehensive care. But how does a small practice like this make time for comprehensive care? For one thing, patients are now sending messages through the office’s portal, and Blazek says she gets several messages per day. She also notes that she has a service in which patients pay a small fee every year in exchange for access to and more time spent with her. “So that means I see less patients per day. I would say an average patient visit is about 30 minutes, but new patients might be an hour or more if they’re complicated and have seen specialists which require me gathering data,” she says. Indeed, although many healthcare organizations of all sizes seem to struggle with patients being active through technology, Blazek says that patients will tell her if something she noted in the record is inaccurate. “I believe in transparency. I believe it keeps you out of trouble,” she says, additionally noting that e-prescribing at her practice, which allows prescriptions to be ordered directly from the patients’ electronic chart, leads to fewer errors compared with a handwritten process.

Meeting Regulations

Many small and solo practices have a tough time in complying with federal mandates simply due to lack of time and resources. But Blazek says that so far, she has experienced little difficulty. “Meaningful Use was actually easy for me,” she says, perhaps to the shock of some. “I attested to Meaningful Use for the first three years, and then the returns diminished so I didn’t bother to do it anymore. Also, since it’s just for Medicare patients, I figured that even if they ding me the 2 percent [penalty for not attesting] who cares, that’s nothing,” she says. Blazek continues, “The first year I got a big check and Practice Fusion made it really easy; I was able to do it all without anyone else’s assistance. I felt good about it doing it correctly, and felt that I would withstand an audit if it came my way.”

To this end, small and solo practices are also nervous about the upcoming Medicare Access and CHIP Reauthorization Act (MACRA) program that will launch its first reporting period next year in which eligible Medicare clinicians will be reporting to a Quality Payment Program. For many high-volume Medicare practices with few resources, this new program is daunting. While Blazek’s practice is not a high-volume Medicare one, she still has to decide if it’s worth taking Medicare insurance due to what will be required of her under the QPP. One plus for her is that she is part of an accountable care organization (ACO), Memorial Hermann, which Blazek calls “a big and successful one.” She adds, “That covers a lot of stuff, and one of the pathways for practices [in MACRA] is being in one of these ACOs that takes risk.”

Blazek says she is not yet panicking about MACRA, since more is still to be determined. But, she doesn’t have real interest in cutting Medicare patients because of how much they mean to her. “It depends on how much it will change things,” she says. A 2 percent [penalty] doesn’t change much for me. My patients pay me a little extra every year anyway, so it may not really matter.” She further says that it feels like every year there’s something new in healthcare policy that everyone fears. But for Blazek, it doesn’t make sense to live in fear when the future is still uncertain. “It’s sort of like skiing,” she says. “You see the mogul and you turn one way or the other, but you can’t see down the hill and you have no idea what’s coming up.”

In the end, Blazek says that, just like with everything else on her solo practice journey, it will work out. “Maybe I won’t take Medicare insurance. But I’ll still see the patients. I have a tight relationship with them and they will still want to see me even if I can’t take their insurance. I will figure it out; I’ve gotten good at that.”

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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.


Driving Success at Regional Health: Approaches and Challenges to Optimizing and Utilizing Real-Time Support

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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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