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At UC Davis Health, Patient-Generated Data Gets Real

February 7, 2017
by Rajiv Leventhal
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For its diabetes improvement project, more than 1.4 million patient-generated health data points have been integrated into the EHR for clinical review and patient health management

Senior leaders at the University of California Davis Health System (UC Davis Health), a Sacramento-based patient care organization serving 33 counties covering a 65,000-square-mile area north to the Oregon border and east to Nevada, have long been focused on using technology to keep patients healthy while lowering costs. One example of this is its Center for Health and Technology Telehealth Program, which was established in 1996 to improve access to specialty neonatal care for expectant mothers living in a small community 60 miles from the UC Davis Medical Center in Sacramento. Today, that telehealth program, which when it started was one of the pioneering projects in the field, is one of the largest telehealth programs in the country.

UC Davis Health’s latest health IT endeavor is one that earned the organization semifinalist status in the 2017 Healthcare Informatics Innovator Awards program. The technology aim of the project, called “Integrating Patient-Generated Health Data to Improve Health,” included diabetes and better blood pressure initiatives that would leverage patient-connected devices and integrate the patient-generated data points into the electronic health record (EHR), thus enabling clinicians to utilize coaching for behavior change when necessary.

More specifically, the clinical aim of the diabetes initiative was to improve the health of diabetic patients through the strategic use of technology and health coaching. From a technology standpoint, the aim was to leverage patient-connected devices (i.e. fitness trackers) and integrate the patient-generated data points (i.e. steps, active calories, resting calories, etc.) into the EHR via a vendor-neutral platform. Similarly, the clinical aim of the better blood pressure initiative was to improve the health of patients diagnosed with hypertension. By incorporating patient-reported blood pressure readings via connected devices into the EHR, clinicians could utilize coaching for behavior change when necessary, officials of UC Davis Health said.

For the diabetic patient initiative, the aim of the health coaches and clinical care providers was to recruit 300 patients over a 12-month period. And for the better blood pressure initiative, the aim of the health management and education team was to recruit 300 patients over a six-month period. The recruited patients were provided an iHealth wireless blood pressure and on-boarded on how to “connect” their device to Apple HealthKit to the patient portal, which would feed into the clinicians view of the patients’ EHR.

Madan Dharmar, Ph.D., an associate professor in residence at the Betty Irene School of Nursing at UC Davis and the Department of Pediatrics at the UC Davis School of Medicine, and dubbed as the “mastermind” of this project, notes that the diabetic initiative was the organization’s first foray into patient-generated health data, and thus it focused on non-actionable data. “So this means metrics around physical activity, nutrition, sleep, how much energy is taken in and being spent, and calories spent and taken in. This is all non-actionable data,” Dharmar says. “The uniqueness of this project is that we wanted for providers to be able to take a four-week period, for instance, so they have a complete understanding and flexibility for how to look at that data and how it’s being presented to them. We needed to capture all of that data and have it within the EHR so they could pick a specific time period, drill into it, and understand the data from that time period,” he explains.

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Dharmar notes that UC Davis Health also wanted to give physicians the ability overlay that data with other clinical metrics which are routinely collected, such as lipid profiles and HbA1c levels so they can have a conversation with the patient. “This way, they can tie that patient-generated health data with the clinical data and help them understand how a behavior change in their lifestyle can have an impact in how they manage that disease. So that’s why we wanted to collect all the data points and have it all within our EHR,” he says.

How Accurate and How Valuable?

An Accenture survey from March 2016 found that the number of U.S. consumers who use wearables and mobile apps for managing their health has doubled in the past two years. What’s more, the research that included a survey of more than 8,000 worldwide consumers revealed that of the one in five consumers were asked by a doctor to use wearables to track their health, such as fitness or vital signs, three-quarters (76 percent) followed their physician’s recommendation.

Despite this uptick in wearables and mHealth app usage, many providers find that issues around data quality and integration into EHRs are still major pain points. Dharmar says that data integrity was a big concern of UC Davis Health’s, as it’s commonly known that if physicians don’t trust the data they’re getting, they won’t use it. “A lot of patient-generated health data integration is focused on the patient entering the data, but there are questions around patient errors and also about the honesty of the patients who are the entering data when they are told they need to meet a certain criteria to meet goals,” Dharmar says. “We automated a lot of that process so that once the data is acquired by a certain device, it gets into our EHR. So there were really no issues around data quality at that point in time,” he says.

Dharmar does point out, however, that the data is coming from consumer devices, and there is inherently an imperfection or accuracy of consumer devices, as they are not meant to be accurate at a “medical grade level or a clinical decision level.” He says that the accuracy of the devices in use “was debated a lot,” and after discussions with physician stakeholders, it was concluded that “since we are focused on a population-level metric, we understand the imperfection of that data, and are looking at shifts in data.” Dharmar continues, “That was one of the reasons we were comfortable in leaning towards consumer devices. As we look more at collecting actionable data to improve care, we are looking at FDA-approved devices which can better accurately capture that information. Like everyone else, we struggle with this problem.”

On the integration front, care management portals have mostly existed outside of the main EHR system, but the secondary portals are difficult for clinicians to manage because each portal/system requires a username and password. Additionally, providers often can’t find the information for patients in one location, and must go to multiple systems and locations to get a full view of the patients’ overall health, officials note. As such, UC Davis Health has developed the platform not just for local population health disease management, but has made it scalable for all patients to use (it just requires turning on the functionality). Through the new integration, patients can provide vital stats to the clinician from one location without having to move all around the EHR and log into and out of additional systems. “Integrating it into the providers’ workflow was a new and innovative way to share data between patients and the clinicians without the clinician having to probe for important health-related data points,” officials say.

In all, for the diabetes initiative, more than 1.4 million patient-generated health data points have been integrated into the EHR for clinical review and patient health management to-date (based on the count of patients recruited for this initiative). For the better blood pressure initiative, more than 2,700 data points have been made available to clinicians for review and patient health management (based on the count of patients recruited for this initiative). Patients participating in the initiatives have provided clinicians with improved visibility into patient health via ongoing data collection; clinicians now have the ability to collaborate with patients using real-time personalized data points, officials say.

Moving forward, Dharmar says that UC Davis Health is strongly moving towards rolling this project out to the rest of their patient population. “We have a network of primary care clinics, but we used three [for this program]. So we are expanding this program to [everyone else].” He says that the idea is also to expand this to managing the community at a population health level—so beyond diabetes and blood pressure.

Laura Martinez, communications and measurements, UC Davis Health System IT, agrees, noting that executive leadership here is “pushing for these types of initiatives because they see the value of population health management.” She adds, “Most projects like this start in one clinic; this started in three with multiple providers on board. It’s the first time we took health-related mobile devices and integrated it into the EHR. It’s just a first step, but it’s an exciting first step.”


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/news-item/ehr/allscripts-sells-its-netsmart-stake-gi-partners-ta-associates

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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