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Pre- and Post-Hurricane Harvey: Healthcare Providers Rely on Health IT to Mitigate Disruptions to Care

October 24, 2017
by Heather Landi
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Two months ago, as Hurricane Harvey approached Southeast Texas, healthcare provider organizations around the Houston area made preparations to try to mitigate overall disruptions to care in the midst of what was forecasted to be a devastating storm.

VillageMD-Houston, a primary care medical group operating 11 clinics across Houston with approximately 80 to 90 physicians, saw an opportunity to use its health IT tools to communicate with its more than 160,000 patients across Houston, in advance of the storm.  Dan Jenson, chief financial officer of VillageMD-Houston, says health technology can play a critical role before a storm, and in the wake of disaster, keeping patients not only informed, but also with access to care. 

“Even before the storm, we have done a lot of work around identifying high-risk patients and reaching out to those patients and building a relationship with those patients. So, as the storm was approaching, we had those high-risk patients in mind, as well as all our other patients,” Jenson says.

“We first stepped back and thought about the different scenarios that could play out,” Jenson says, noting that the medical practice leaders had a historical view of the flooding caused by Tropical Storm Allison in June 2001. “We thought about the different scenarios—if we lost power at the main clinic site, if we lost our phone system. What would it look like if we had multiple days of people not being able to get into the clinics? We really played out each one of those scenarios and thought about ways that we could mitigate the loss of patient care,” Jenson says.

In the days before Hurricane Harvey was forecasted to make landfall, which it did August 25, VillageMD leaned on its cloud-based electronic health record (EHR) system to send out messages to all the practice’s patients to alert them of the severity of the storm and inform them about how they could get in contact with their provider, or an on-call physician.


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“If our phone lines were up, that we gave them our normal on-call physician number that they could call in. We also let them know that if, for any reason, our phones went down, we’d still have our answering service line available for folks to call in and be able to speak to an on-call physician. And then, we did our best to get facilities ready for the storm, so we could recover as quickly as we could following the storm.”

As Hurricane Harvey was churning its way up the Gulf of Mexico, Jenson credits the group’s EHR vendor, athenahealth, for working with medical practice leaders to get messages out to patients, whether via text, email or phone calls, two days before Hurricane Harvey’s forecasted landfall. “athenahealth has a pre-built way, through its communicator application, to reach 10,000 of your patients a day through campaigns. We’ve got over 150,000 active patients that we needed to reach out to at one time. So, we called athena on Wednesday, and overnight, by Thursday, they built an application for us that could process all of our patient applications, so we could get out more than 150,000 messages via text, email and phone."

Dan Jenson

He also notes that the practice used the tools available within its EHR to reach out to high-risk patients with specific needs.

“We have that high-risk patient list; a cohort of patients that we know have complicated, multiple chronic diseases. So, they might need special assistance, such as they might need oxygen or they are on dialysis, and it’s a situation where, once a month, we are reaching out to these patients anyway to see how they are doing. We reached out to those patients before the storm, telephonically, to give them some words of comfort and let them know what numbers to call to reach a provider. I think that was really helpful, just getting our patients ready,” Jenson says.

In the Aftermath of Hurricane Harvey

Electronic communication and cloud-based tools enabled many healthcare providers to continue to deliver patient care, whether in-person or remotely, during and after the storm.

Advanced Diagnostics is a small, eight-bed hospital and specialty surgical center in east Houston that operates an active emergency room, and organization leaders made the decision to stay open throughout the hurricane. “We saw patients in the ER as well as the inpatient operations and we ran the operating room all the way up until Friday (August 25) and then shut the ORs down due to travel, but our inpatient and ERs stayed opened throughout,” says Rob Turner, CEO of Advanced Diagnostics Hospital and Clinic System and chief operating officer of Advanced Diagnostics, the parent corporation.

Turner stresses the importance of preparing and reviewing disaster preparedness plans and then carefully evaluating the options—whether to close or stay open—when faced with a severe weather threat. Based on the local geography, Turner and other organization leaders felt confident that the facility would not flood or be an issue for patient safety.

“We did what every hospital should do. We ran our emergency checklist; we checked our emergency power sources, checked our generators to make sure everything was doing what it was supposed to do. We also checked our food supply,” he says, adding, “As far as IT was concerned, we run a redundant infrastructure for the electronic medical record (EMR) and for our Wi-Fi and regular systems here at the hospital that require internet connectivity.”

While many Houston residents were prepared for flooding, rain and wind, Hurricane Harvey brought unprecedented levels of rainfall, almost 52 inches during a five-day period, according to the National Weather Service. Texas state officials reported that at least 42,000 people evacuated to shelters during the storm. As the storm raged on, a nearby tertiary care hospital, East Houston Regional Medical Center, closed due to flooding, and Advanced Diagnostics began to take on patients from that hospital as well, Turner says.

Rob Turner

While Advanced Diagnostics' hospital operations continued throughout the storm, many employees either had flooding in their own homes or couldn’t get to work due to impassable roads. Advanced Diagnostics also uses an athenahealth EMR system, and Turner credits the use of cloud technology, and its connectivity, as enabling providers to reliably access patients' records throughout the storm, while also allowing non-clinical staff to work remotely until the floodwaters receded. “We never lost connectivity; at times like that, it’s good to know that your EMR is going to function through it. Our plan was to stay fully functional through the storm and the system enabled us to do that.”

VillageMD-Houston closed its clinics during the storm and reopened that following Thursday, but Jenson says cloud technology provided the on-call physicians, who were working remotely, with the connectivity needed to access critical patient records. “Regardless of whether the patient was from the Southeast side of Houston or the Northwest side of Houston, for one physician to be able to access those records for those patients who were calling was very helpful. Also, because of the mobile applications that athena has through both the iPad and through a cellphone, even if Wi-Fi went down at a physician’s house or even if the power went out, physicians were able to still use cellular data to access the information they needed to provide care,” Jenson says.

What’s more, VillageMD clinicians triaged some patients with minor health issues over the phone. “The emergency lines were overwhelmed with calls throughout the floods, and I think having folks not clog up the emergency lines with issues that could be handled by a primary care physician is beneficial to the system.”

What’s more, in the days and even weeks that followed, access to healthcare remained a significant issue for Houston and the surrounding areas as the recovery process began. Jenson says prescription refills were a significant healthcare need as patients were not able to get into see a doctor during the storm, and health IT helped to mitigate this problem as well. “We’re able to leverage the standing orders that we have within our EMR where our nurses and our non-physicians can work with patients that need to get refills of some of those chronic medications, as opposed to having patients come into the clinic. We were able to really utilize those standing orders to get blood pressure medicine, insulin medicine and other prescriptions out to folks that needed them,” he says.

There were a number of other unique healthcare needs following the storm. Data from athenahealth’s research team, based on an analysis of appointments from 1,000-plus providers in the 44 Harvey federal disaster zones in Texas and Louisiana, indicates that providers saw an increased number of select acute conditions, including injuries (11 percent increase) and respiratory conditions (10 percent increase). The largest increase in injuries were to the lower extremities and the shoulders/arms (both more than a 14 percent increase from the expected), according to the data.

Turner with Advanced Diagnostics Hospital says, “This side of town, there was quite a bit of flooding in small neighborhoods, so we’ve seen some cellulitis (bacterial skin infection) from people spending too much time in the water. We’ve seen mostly some of the lower limb-type injuries; the population is kind of a mixed bag of diabetics and industrial injuries, so you see a lot of that anyway. We’ve seen a small spike in that from all the floodwaters.”

Jenson notes that there have been a few lessons learned in the aftermath of the storm, such as developing a staffing model to quickly mobilize employees to get the clinics back open. “It’s important to have a plan for different outcomes that might occur after a storm or an emergency to get the clinics back up and running quickly, because, from our experience, you will have pent-up demand, not only from your patients, but also the patients that we’re seeing who were displaced from their clinics because those clinics were flooded or are still not operational."

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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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