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At UCHealth, a Sprint Toward EHR Optimization—at an Individual Level

November 1, 2017
by Rajiv Leventhal
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UCHealth’s CIO shares how his health system has improved physicians’ EHR use

It was about eight years ago when clinical and IT leaders at UCHealth in Aurora, Colorado first started their EHR (electronic health record) journey with a go-live at the health system’s academic hospital, the University of Colorado Hospital. And as the health system kept on growing and merging with other organizations, the EHR rollouts continued across the enterprise as well.

But while leaders at UCHealth were seeing great adoption of the technology, as well as great use of the EHR that was also driving value, the reality was that the health system needed to help its physicians become more efficient in their use of the systems. “It felt like we were working too hard for the EHR, rather than having the EHR work for us,” says Steve Hess, CIO at UCHealth.

Hess presented on his organization’s initiative, called “EHR 2.0 Sprint,” at the CHIME (College for Healthcare Information Management Executives) Fall 2017 CIO Forum on Nov. 1 in San Antonio, Texas, and also spoke with Healthcare Informatics separately about the core processes and strategies involved in the project. Having tried numerous methods to improve physician-EHR workflow, UCHealth now deploys the “EHR 2.0 Sprint,” which is a two-week intensive immersion in clinic with a small team.

The motivation behind this initiative, Hess says, was that while UCHealth was already doing a lot of things to improve its general use of its Epic EHR, it was noticing that the individual clinics and providers were still struggling. “There were doing documentation at home and finishing their notes well after patients already left, so we needed to think of a different way for doctors, nurses and schedulers to become more efficient,” Hess says. “So we redirected resources that were spent on global optimization efforts and had [those people] instead go into the clinics, shadow the doctors and nurses, and help them improve the way they were using the EHR.” While UCHealth had already trained many of these folks years ago, and three EHR versions ago, “they weren’t able to take advantage of the new functionality. So having us go into the clinics really helped them,” Hess says.

Indeed, while the organization’s original optimization efforts helped its physicians in some ways, the benefits were not very visible to them, says Hess, noting that doctors are mostly concerned about how IT can help get them through their days without major burden. “We [designated] two weeks where we had a team go in to spend time with them, and there’s really nothing like it. Physicians don’t have time to come in before clinic hours, during lunch or after clinic hours to come to our webinars for tips and tricks on how to [improve] their EHR use. So we invested the time to go into their practices, and show them the low-hanging fruit, and that was well received,” Hess says.

Importantly, the initiative involved no new resources or FTEs; Hess’ team took the existing resources that were devoted to other optimization efforts and redirected them to helping physicians at an individual level. “We had 11 people, but not FTEs, and they were led by a project coordinator who ran the show,” Hess says. “We wanted to use the agile methodology, with a physician informaticist, an individual who reports to our CMIO, [along with a few] Epic ambulatory analysts and some trainers. We looked at physicians’ templates and how they were doing things in the EHR, and we were able to show them some new ways they can be doing things and newer versions of the EHR that they never learned,” Hess says.

Leaders at UCHealth believe that there are two core pieces that are aligned with physician burnout. The first is the use of technology and tools, and the second is making sure that everyone in the organization is working at the top of their scope [of practice], Hess says. “Making sure everyone is working to the top of their authority and doing things that will set up the patient and the doctor for success, and also improving the use of tools, is a parallel path. And we’re doing both of these things,” he says.

UCHealth has about 540 clinics, so while Hess says he would love to have the resources to go into the clinics every week, that’s just not feasible. But, he notes, his team is working closely with operational and clinical leaders so that they can show the pre- and post-burnout scores, net promoter scores, and the improved use of the tools to show the value that has been gained.

What’s more, the feedback from the doctors has been terrific, Hess attests. “They love the individual attention and the fact that this is two weeks long.” However, he adds, the true test will be seeing if this initiative is sustainable and how many doctors and clinics the team can get to on an annual basis. “What will the scores look like a year from now? The reality is that the EHR is constantly evolving, so in a perfect world we are revisiting every clinic and doctor on a routine basis,” he says. “Also in a perfect world, you would make the EHRs as intuitive as Amazon and other best-in-class user interfaces. But there are obviously some limitations,” Hess admits.

He adds that the goal is not to tie this initiative to the increased number of patients a doctor is seeing per week, but rather only tie it to provider satisfaction and burnout. “Hopefully doctors can now go home and have a work/life balance that is different than before. It’s those little things, and maybe it’s more subjective than objective, but hopefully it goes back to why they became a doctor or a nurse in the first place,” Hess says.

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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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