Opening the HIT Summit in San Diego, UCSD’s Chris Longhurst Examines the Potential for EHR-Fueled Clinical Transformation | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Opening the HIT Summit in San Diego, UCSD’s Chris Longhurst Examines the Potential for EHR-Fueled Clinical Transformation

January 24, 2017
by Mark Hagland
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Christopher Longhurst, M.D. shares with Health IT Summit-San Diego attendees his perspectives on what is being learned around EHR-facilitated clinical transformation

In a wide-ranging opening keynote address, Christopher A. Longhurst, M.D., CIO at UC San Diego Health, offered his perspectives on the healthcare IT-facilitated clinical transformation beginning to take place now in earnest across U.S. patient care organizations, on the first day of the Health IT Summit in San Diego, sponsored by Healthcare Informatics. Dr. Longhurst, a pediatrician who had been CMIO at Stanford Children’s Health before coming to UC San Diego Health as CIO a little over a year ago, told attendees gathered at the Omni Hotel San Diego on Tuesday morning, that now is absolutely the time for healthcare IT leaders to help their patient care organizations turn the corner from the immediate post-electronic health record (EHR) implementation phase, to the vital work of improving patient care quality and outcomes through EHR implementation and clinical transformation.

Longhurst began his keynote address by framing the context of the current moment in clinical informatics in U.S. healthcare. He reviewed what happened when a December 2005 article, “Unexpected Increased Mortality after Implementation of a commercially Sold Computerized Physician Order Entry System,” appeared in the journal Pediatrics, summarizing a documented increase in mortality at Children’s Hospital of Pittsburgh, after EHR implementation there. As Longhurst noted of the article’s core finding, “It was a bombshell result. We gave a lot of thought to this,” he said, “and I wrote a letter to Pediatrics, along with Dr. Classen”—David Classen, M.D. of the University of Utah Health Science Center. Looking at the immediate result of increased mortality at Children’s Hospital of Pittsburgh following EHR go-live, he said, speaking of the analysis of it that he and Dr. Classen undertook, “We thought it was inadequate preparation along with bad order sets.”


Christopher Longhurst, M.D.

As a result of the heightened awareness of the potential for unanticipated negative impacts on patient outcomes in the immediate aftermath of EHR go-live, Longhurst talked about how he and his colleagues at Stanford Children’s Health (at that time still known as Lucile Packard Children’s Hospital) engaged in very careful, thoughtful analysis of outcomes as they were going live with their EHR implementation, and in its immediate aftermath. Indeed, as CMIO, he had asked the hospital’s chief quality officer to monitor very closely all mortality trends in their facility, as they moved forward through post-go-live. As it turned out, their implementation revealed a dramatic decrease in patient mortality: mean monthly adjusted mortality rate for the hospital overall decreased by 20 percent in the 18 months after EHR go-live, with an estimated 36 children’s lives saved during that time, based on an analysis of their outcomes. In an article that he and his colleagues from Lucile Packard published in the May 2010 issue of Pediatrics, entitled “Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System,” Longhurst and his co-authors attributed the difference between the outcomes at their organization and those years earlier at Children’s of Pittsburgh, to differing implementation strategies, and offered that he and his colleagues had learned a great deal from what their peers at Children’s of Pittsburgh had discovered in their post-implementation; and that a well-executed EHR implementation is indeed fully capable of reducing mortality rates among pediatric patients.

Longhurst also referenced an April 2010 article by Jane Metzger et al in Health Affairs, “Mixed Results In The Safety Performance Of Computerized Physician Order Entry,” which found that, among hospitals implementing six different commercial EHR products, patient safety impacts from EHR implementations varied across every vendor solution as implemented by every hospital, to make the point that the relative success of EHR-fueled patient safety work will depend on what goes on in every patient care organization that attempts such work, not on the commercial EHR product used. In the Metzger study, he noted, “Six different vendors were the safest of six different vendors. So what does that tell us? It’s not the software that you buy. It’s about us. It’s about implementation. Less than 20 percent of outcome was based on the vendor, 80 percent was the implementation,” he said of that study.

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Moving into a new era in clinical transformation, Longhurst emphasized, will require some enterprising ingenuity, and above all, leadership and a passion for leveraging health IT effectively to improve clinical outcomes. He spent some time recounting a clinical case at Stanford Children’s Health that broke new ground in that regard, and which was recounted in an article entitled “Evidence-Based Medicine in the Clinical Era,” in the Nov. 2, 2011 edition of New England Journal of Medicine, with Jennifer Frankovich, MD., the lead author, and Dr. Longhurst and Scott M. Sutherland, M.D., as coauthors.

As the coauthors wrote in the NEJM article, “We recently… admitted to our service a 13-year-old girl with systemic lupus erythematosus (SLE). Our patient’s presentation was complicated by nephrotic-range proteinuria, antiphospholipid antibodies, and pancreatitis. Although anticoagulation is not standard   practice   for   children with SLE even when they’re critically ill, these additional factors put our patient at potential risk for thrombosis, and we considered anticoagulation. However, we were unable to find studies pertaining to anticoagulation in our patient’s situation and were therefore   reluctant   to   pursue   that course, given the risk of bleeding. A survey of our pediatric rheumatology colleagues—a review of our collective Level V evidence, so to speak—was equally fruitless and failed to produce a consensus. Without clear evidence to guide us and needing to make a decision swiftly, we turned to a new approach, using the data captured in our institution’s electronic medical record (EMR) and an innovative research data warehouse. The platform, called the Stanford Translational Research Integrated Database Environment (STRIDE), acquires and stores all patient data contained in the EMR at our hospital and provides immediate advanced text searching capability. Through STRIDE, we could rapidly review data on an SLE cohort that included pediatric patients with SLE cared for by clinicians in our division between October 2004 and July 2009. This “electronic cohort” was originally created for use in studying complications associated with pediatric SLE and exists under a protocol approved by our institutional review board.” Using that data set, Frankovich, Longhurst, and their colleagues ultimately chose the path of anticoagulation for that patient.

As Longhurst explained it to his audience on Tuesday, “In the fall of 2009, I was on service, and there was a patient with lupus. She was well-known to us, and had been served many times before. She was flown by LifeFlight, had multiple systems failure. I was standing at our bedside with our intensivist and one of our pediatric rheumatologists [Frankovich]. And the rheumatologist said, she’s losing a lot of protein in her urine, might she be at higher risk for clotting? So she looked it up in the literature. And how many papers have been published about teenagers with lupus and clotting issues? Zero. So she went to our subspecialists. And the first one said, I would absolutely anticoagulate. The second said, I would absolutely not. Both had had cases like this.” What Dr. Frankovich was able to do was to use information from the STRIDE data warehouse, to research past cases, including identified cases, of lupus, with complications. She and her fellow physicians found 98 lupus cases from the previous five years, and divided them into various cohorts based on different clinical elements. Ultimately, based on finding a significantly higher risk of clotting among patients with lupus whose cases most closely approximated this one, they pursued anticoagulation. “What we know,” Longhurst told his audience, “is that in the absence of published data, we made the based and most evidence-based decision we could under the circumstances. And if that were my daughter in the hospital, I would hope that she would get the same care.”

Longhurst shared with his audience that the key point of all of these articles and analyses is this: the potential for EHR-facilitated clinical transformation is huge—but healthcare IT leaders must help lead clinical transformation efforts strategically and thoughtfully, while also sorting very carefully through all the intended and unintended consequences that might emerge. “I think that electronic health record implementation is exactly the right thing to do; it improves the care we provide,” he said. “But we all know that it leads to unintended consequences. And we’re not yet really using the aggregate data in the system to improve care.”

Among the points he made included references to recommendations from the Institute of Medicine that urge healthcare leaders to address both the anticipated and unanticipated consequences of healthcare IT implementation, and also urge healthcare IT leaders to architect clinical decision support alerts that are clinically helpful. Longhurst referred to IOM’s having noted that most CDS alerts are around excess utilization.

In the end, Longhurst told his audience, “Every quality improvement project involves some IT component. But we [healthcare IT leaders] need to be leaders. We need to lead change. We need for IT implementation to support the overall strategy of operating better as a system, and we need to be thoughtful about it.”

 

 


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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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