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A Pioneering Spanish CIO Shares His Perspectives on the New Healthcare

November 23, 2016
by Mark Hagland
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At WoHIT2016, Spain’s Vicent Moncho Mas shares his learnings around clinical transformation and capitation

In western Europe, as in the United States, IT-facilitated clinical transformation remains a work in progress, with tremendous variations by geography and by type of patient care organization. One organization in Spain that has made tremendous strides—and which became one of the first European hospital organizations to receive “stage 7” recognition from the HIMSS Analytics division of the Chicago-based Healthcare Information and Management Systems Society (HIMSS), per its EMRAM schematic around electronic health record (EHR) development—is the Hospital de Dénia/Marina Salud S.A., in the suburb of Valencia called Dénia, on the east coast of Spain. Indeed, the leaders of the hospital received the prestigious Davies Award from HIMSS in 2015, and the hospital’s CIO, Vicent Moncho Mas, was presented with the award at HIMSS’ World of Health IT conference in Riga, Latvia, that year.

Moncho Mas spoke of the journey into digitization and clinical transformation on Tuesday, Nov. 22, at World of Health IT 2016 (WoHIT2016), being held this week at the Centre de Conveniones Internacional de Barcelona (CCIB), in Barcelona, Spain.

Speaking of the project that is now optimizing clinical IT after having fully digitized clinical and staff operations, and expanding into patient and community engagement via mobile outreach, Moncho Mas told his audience at the CCIB that “This is a special project. If we want to engage patients, we need to define new information channels. On the other hand, we need to train patients, we need to teach patients for this,” he said, speaking of the opening of a patient portal, and his organization’s plunge into population health work. “The patient portal is the highway; it is the door that we open to our patients for channeling their clinical information. And it’s quite important to have this portal, with some standard functionality, such as access to clinical notes, to records, lab results, radiology, etc.,” he told his audience. “It’s quite important to share this with the patient. Of course, we also need to support mobile apps. We need to give all the information not only on a web platform but also through a mobile platform, because patients always have phones with them, but not laptops.”

In addition, Moncho Mas noted, “Another information channel that we’ve established is the messaging system. And messaging with patients must be like email and must be available inside the platform. And that implies security. We need to be able to assure that all of our information for patients is safe for them.” In addition, with a high rate of chronic illness in the patient population of the health system, “It’s very important for patients to learn about their chronic diseases, such as diabetes,” he added.

Vicent Moncho Mas of the Hospital de Dénia speaks on Nov. 22 at WoHIT


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One area of particular interest has to do with the fact that the leaders of the Hospital de Dénia have made lab results available to patients in real-time. “In Spain,” Moncho Mas said, “when we have results outside the limits”—abnormal results—“we put a star or asterisk there in the patient record. And some physicians say, what happens when the patient sees an asterisk? We have to teach patients how to interpret results, how to understand those lab results. Another element is knowledge about their actions, with regard to a healthy lifestyle. For instance, a diabetic patient has to know about what they have to eat, measure, etc. Many patients besides diabetes. And we have to provide clinical information to our patients in a way that is adapted to consumer needs and knowledge.” In addition, on the horizon for his organization is the public sharing of more refined indicators around population health, he told his audience.

Meanwhile, just prior to his presentation at WoHIT, Moncho Mas sat down at the CCIB with Healthcare Informatics Editor-in-Chief Mark Hagland to discuss the progress his organization is making along numerous dimensions. “It is important to keep in mind the operational context around what we’re doing,” he said. “Spain is divided into a number of regions, which have a great deal of policy autonomy. Our hospital is located in the Region of Valencia, which is one of 17 regions with autonomous health ministries. It is a 290-bed hospital built on a public/private partnership model, which is a relatively recent one in Spain. What happened is that our hospital was created through a contract with the government that was signed in 2009. Our facility opened in 2011, and we are operating on a 15-year contract for operations. Based on that contract, we are working under full capitation; we receive just 720 euros per patient per year—a very small amount.” (At the time of the writing of this article, the euro-dollar exchange rate was 1:1.06, meaning that €720 PPPY equaled $763.20 PPPY.)

“What’s more,” Moncho Mas said, “we have a large population of seniors, and many of those have chronic diseases, most commonly diabetes. Among that population are northern Europeans [British and Germans especially] who spend their winters in the Valencia area.” (The €E720 PPPY capitated payment that the organization receives for patient care does not include separate payments for pharmaceutical costs and the costs of such items as ambulance transportation, personal medical equipment such as prostheses, etc., for which the hospital does receive additional payments for cost.)

Given the capitated payment involved, naturally, population health management and care management are exceptionally important elements in how the Hospital Marina Salud de Dénia is caring for its patients. At its core, Moncho Mas noted, is the increased empowerment of primary care physicians in a care management context. The organization employs multidisciplinary care teams that work in integrated health centers (as is usual in Spain, the physicians are directly employed by the organization). What’s more, because of the high cost of hospitalization and of ED visits under a capitated payment system, great care is taken to optimize the site of care for patients. Thus, all 11 primary care-based health centers contain urgent care centers, to deflect cases of low clinical intensity away from the system’s hospital EDs.

Asked what the secret to success under capitation is, Moncho Mas said, “The main objective is to keep one’s population healthy. We have a high population of chronically ill older people, especially from the UK and from Germany, many of whom winter in the Valencia area. Right now, 37 percent of our care costs are hospital-based; we’re trying to reduce that proportion.”

And his biggest challenges as CIO? “The biggest challenge was becoming paperless, as well as optimizing clinical documentation and clinician workflow. The reality is that the healthcare industry changes slowly here as elsewhere. And the clinicians need a lot of reassurance.” Asked how he sees the role of CIO leadership in facilitating the kinds of transformational change taking place in Dénia, Moncho Mas said, “CIOs need to let go of a focus on the technical aspects of all this and to look at the human aspects, especially with regard to patients. What we need to do as caregivers is to transform ourselves into consultants to patients. We need to become truly patient-centered, and we have to begin to engage in that language. And we have to create interconnections with the diverse communities within our broader community.”




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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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