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At Tampa General Hospital, a Newfound Focus on Clinical Process Improvement

October 26, 2017
by Rajiv Leventhal
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In Florida, one hospital set out on a path to attain standardization for how it cares for its patients

Last year, Tampa General Hospital (TGH), a 1,011-bed teaching hospital in Florida, initiated a clinical process improvement (CPI) program aimed at enhancing standardization and efficacy of treatment for conditions identified as high priority. At the time, officials at the patient care organization noted that the core goal was to develop scalable and repeatable models to tackle difficult clinical initiatives and improve patient outcomes—an objective that Peter Chang, M.D., CMIO at Tampa General Hospital, confirmed in a recent interview.

“As a doctor, naturally your inclination is to want to make the lives’ of your patients better and make them live longer with less comorbidities. So this initiative was born out of [simply] providing better care for our patients. And when we looked across the organization, we lacked a lot of standardized methodologies for how we care for them,” Chang says. He gives an example of a patient coming in for a disease process, but one group of physicians might manage that differently—not incorrectly, but differently—than another group. “So with variability comes variability in outcomes,” says Chang. “We have known this problem exists in the U.S., but also in our organization, so we set out on a path to try to attain standardization for how we care for our patients.”

Early on in the CPI initiative, a top priority was the early diagnosis and treatment of sepsis in the emergency department (ED), where 80 percent of TGH’s sepsis cases originate. TGH tested several known methodologies, yet they lacked scalability and self-service access to the information that stakeholders needed to make quick improvements, according to officials. These methods did not provide insight into the actual process or delivery of care (rather only focusing on outcomes data), which is required for sustainable and scalable process improvement, TGH officials noted.

So clinical leaders at TGH opted for another approach, which involved electronic health record (EHR)-generated alerts and treatment advice, and a clinical process improvement platform from Minneapolis-based LogicStream, which enabled clinical leaders to review clinician response times and treatment decisions in real time.

Chang notes that with the advent of EHRs, other avenues have opened up. Before, when everything was on paper, he says, there would be a paper order set that would have to be located for different things to be enacted. But now, with clinical alerts living inside the EHR, they can kick off different processes to ask the provider, “Do you think this is what’s going on, and if so, please follow the accompanying treatment track.” And Chang adds that much of this is driven by TGH’s quality reporting for CMS (Centers for Medicare & Medicaid Services) star ratings, value-based purchasing, and U.S. News and World Report hospital scores, all of which take some account of quality and outcomes into their calculations. “So there is a secondary gain for wanting the hospital to perform at a higher level. We want to show folks that we treat our patients well here. So that led us onto our path for process improvement and bettering clinical outcomes,” he says.

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Regarding sepsis, Chang says that by looking at the Sequential Organ Failure Assessment (SOFA) score (used to track a person's status during the stay in an ICU to determine the extent of his or her organ function or rate of failure) or examining the “Surviving Sepsis” guidelines, one would get differing opinions on what doctors believe is the correct way to manage sepsis. But nevertheless, CMS has adopted a 3-and 6- hour rule for a core quality measure—the Sepsis CMS Core (SEP-1) Measure.

For TGH clinical leaders, being able to leverage its Epic EHR to allow these processes to get kicked off became a key priority. “We created a sepsis alert order that goes into the EHR and is an overhead page to everyone in the ED to say that there’s a sepsis alert in X room [for example],” Chang explains. “So when that happens, it initiates a chain reaction of events from nurses to physicians to pharmacists to make sure that the correct protocols are being followed. And the use of LogicStream in that sense allows us to analyze the compliance and usage of the elements that we have built into the EHR,” he says.

Chang says that Epic has two major tracks in its system to help treat patients: best practice advisories and order sets. The best practice advisory, he continues, looks at information that lives within the chart, be it labs, documentations, vitals, or discrete data inside the EHR, and will kick off an alert to a nurse or physician, leading that person to an order set. The nurse or physician can then see that even though the patient meets the criteria for labs and vitals, maybe he or she just has the flu and is not septic.

“It gives you a way to ‘opt out;’ the computer just knows the patient from what’s inside the EHR. So we use best practice advisories to alert nursing in triage and physicians to say that their patient could potentially have sepsis based on multiple criteria, do you want to go ahead and initiate that sepsis order alert, and do you want to continue down the path of using the order set we have outlined to achieve the 3- and 6- hour timeframe from the SEP-1 measure?” says Chang.

Currently, only physician leaders are using the software since it’s their way of trying to manage their doctors, so TGH is just starting to publicly display order set utilization scores, says Chang. He adds that the LogicStream platform doesn’t adjust for volume, so if one doctor is working five times the number of shifts of another doctor, the former’s compliance will appear higher because he or she is using the order sets and alerts more often. But, Chang notes, LogicStream does give good insight into how people are managing the alerts. “They are sometimes dismissing the alerts, as they should, but are they doing that too much?” he asks.

To this end, when more data comes in, an organization can come up with a range based on what it knows. So if 10,000 patients come in, 5,000 of whom are final coded for patients, in that instance, TGH practitioners should be in the range of 50 percent compliance with this advisory, Chang explains. “We can come up with those broad stroke numbers to get the picture and follow the best pathway when appropriate. So it’s a ‘scorecard’ to see how this individual is using the system, and how the person is prompting the alert. If we reverse engineer the data, we can find specific things, such as OK, provider X had five patients that didn’t meet the measure, but why? And then we drill through and if we find that the doctor is not using the order set or dismissing the alert, that provides an education opportunity to see why the doctor is getting the alerts but not responding to them,” he says.

As a result, Chang says, clinicians in the ED have become more engaged in their performance data as it relates to sepsis outcomes. “No one wants to cause harm to a patient,” says Chang when asked if doctors are OK with these new processes. But, he adds, “You have to paint that picture to them explaining why it’s important rather than tell them ‘you have to do this.’ The alerts can be firing too many times; it has to make sense.”

And while it’s still early on in the process, initial results suggest that TGH doctors will quickly understand the initiative’s importance. In one instance, TGH increased the use of IV lactated ringers for sepsis patients by 50 percent within one week, according to officials.

Chang says the biggest challenge with an initiative like this one is change management. “You can use technology, tools and tricks to present people with data and provide explanations, and allow them to drill down into it, but getting people to realize the importance of it and then start to shift in how they’re thinking about septic patients is the challenge,” he says.

“A lot of light bulbs have gone up in regards to our process,” he adds, noting that TGH also has processes outlined for conditions more well-defined, such as stroke. But stroke is a small bucket and a small group of patients, so it’s a much more focused effort on getting the patient what he or she needs. Sepsis, on the other hand, is a very broad category—it could be your 10-year-old kid or a 95-year-old grandmother, or anyone in between, Chang says. “So change management is opening up the window. Could that person be septic or could he or she be developing sepsis, and why? I think that’s the big issue—getting people to see the importance of using the order sets and complying with the alerts.”


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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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