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At University Hospitals in Cleveland, MD and IT Leaders are Making Strides to Reduce Provider Burnout

March 21, 2018
by Heather Landi
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Surveys suggest that more than half of U.S. physicians show symptoms of burnout, and other studies have linked burnout to work process inefficiencies and administrative and documentation burdens, particularly the use of electronic health record (EHR) systems.

A time and motion study by the American Medical Association and published in the Annals of Internal Medicine in the fall of 2016 found that during office hours physicians spent nearly 50 percent of their time on EHR tasks and desk work. Researchers concluded that for every hour physicians provide direct clinical face time to patients, nearly two additional hours is spent on EHR and desk work within the clinic day, And, outside office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work. A separate study published in the Annals of Family Medicine last fall also found that primary care physicians spend more than one-half of their workday, nearly six hours, interacting with the EHR during and after clinic hours.

In light of the ongoing administrative and documentation burdens that providers face, healthcare leaders are concerned about physician satisfaction and the link to patient safety and care quality. According to the Agency for Healthcare Research and Quality (AHRQ), physician burnout can threaten patient safety and care quality when depersonalization leads to poor interactions with patients and when burned-out physicians suffer from impaired attention, memory and executive function.

To proactively address provider burnout, executive leaders at Cleveland-based University Hospitals accelerated a partnership with the health system’s EHR vendor, Allscripts, to address EHR usability and workflow issues, with the aim of making the EHR system more user-friendly, seamless and interoperable.

“This notion of physician burnout, or stress to physicians in their workplace, is something that has been brewing and getting progressively worse over last three to five years,” Cliff Megerian, M.D., president of University Hospitals’ Physician Services, says. In his role, Megerian oversees a physician network comprised of 2,500 physicians across the 18-hospital health system.


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Megerian also is a professor and surgeon, and, as a practicing physician, he sees firsthand the usability issues with EHRs. “The EHR is a fairly recent innovation; it was mandated as part of the American Recovery and Reinvestment Act, so many mature physicians have grown up in an environment where they were dictating and having their dictations transcribed or they were writing on paper. This is a fairly new burden, within the last decade, and I think it is stressing many physicians because many believe it is forcing them to spend less time with their patients and more time with the computer.”

As part of its efforts to address provider burnout, UH conducted physician surveys and responses to those surveys point to the administrative burden of the EHR, as well as other regulatory hurdles, as an ongoing source of stress. “The reason this has risen to the forefront is because the survey results are showing that it’s the EHR,” Megerian says, adding, “And the survey results show that it’s agnostic as to which brand of EHR is being used.”

UH project leaders took a number of steps to help minimize administrative burdens and streamline physicians’ workload. The end goal, Megerian says, was to reduce the amount of time clinicians have to deal with counter-intuitive solutions, giving them more time to spend with patients, and thereby reducing the likelihood that they suffer from burnout and decreased job performance.

The project team, which consists of UH’s IT team and Allscripts’ team, first addressed stability issues in the EHR platform. “One of the earliest complaints was that the system was logging me out, or the system was going down, and we have been very successful in working with Allscripts, as well as our own IT people, in making the system a lot more stable, and the amount of downtime has logarithmically decreased,” Megerian says.

The project team also worked to create a bridge between systems to provide a more unified view and better access to information across the 18-hospital UH system, or what’s called OneUH. “Many hospital systems that have EHRs have different versions for different platforms, so you have an inpatient system, an outpatient system, a system that works with your oncology patients, and another system for cardiology, and they may be under the same vendor, but they are different. We worked with Allscripts to create a bridge between the systems,” he says, adding, “It’s a huge project and we’re still in the middle of that.”

Megerian asserts that close collaboration with Allscripts has played a key role in accelerating improvements with EHR usability and physician satisfaction. “About a year and a half ago, the partnership accelerated as we really became cognizant of the fact that we can’t, on our own IT platform, make every improvement without them making improvements on their end.”

As a result of this ongoing initiative, UH project leaders have noted a number of improvements—an increase in application response time, a reduction in dictation software issues, and improved screen-flip time. Application response time has increased 30 percent from March 2015 to January 2017 as a result of the collaboration between UH’s IT team and Allscripts’ team, Megerian notes. And, Citrix log-in times have improved 36 percent. UH physicians also use Nuance’s Dragon dictation application, and there has been a 75 percent reduction in dictation software issues.

With regards to improving screen-flip time, Megerian says in the past doctors complained that it took too long to flip screen to screen. “It was 1.47 seconds, and now it’s 1.09 seconds. That is actually better than Allscripts’ documented performance standards, and they worked with us because our doctors wanted improvements, our doctors wanted speed.”

And these IT improvements lead to increased productivity for clinicians, Megerian notes. “With reducing screen-flip time from one and a half seconds to one second, if you think about a physician seeing one patient, he or she is going to be going through six screens, so that’s six seconds for six screens, versus nine seconds. Or, it might not be six screens, but 15 screens if you do the billing, and the CPT coding, and the ICD 10 coding. That physician is seeing 30 patients a day, so you can do the math. That’s additional, unnecessary time that you could have been completing your notes and not spending extra time in the office or taking away time from your patients,” he says.

As part of this initiative, UH also developed a physician services and IT panel comprised of physicians and physician leaders, and has increased the number of meetings between Allscripts teams and physicians. “We created physician work groups that create a list of challenges they are having and those are moved to the top of the queue for our IT team and Allscripts team to remedy. And those physician work groups meet on a regular basis,” he says, adding that Allscripts CEO Paul Black personally visits several times a year to meet with executive leadership and physicians to learn about ongoing EHR challenges.

Megerian emphasizes that accelerating the health system’s partnership with its EHR vendor was critical to effectively addressing EHR usability issues. “If you are a physician organization and you buy a product, I don’t see how it’s possible to improve some of the functioning of that product without partnering with that vendor. Allscripts partnered with us and we’re showing significant signs of success. I’m not saying it’s perfect, it’s not. But, the company has been fantastic in partnering with us to improve things beyond the factory specifications,” he says.

Moving forward, the UH project team plans to continue making improvements, guided by feedback from physician work groups. “We are doubling down on creating more transparency between the vocal physicians who have an interest in IT and improving the EHR and create conduits and touchpoints between our own CIO and our own CMIO (chief medical information officer) and through extension, through Allscripts,” he says. “It’s important to understand the providers’ expectations; you have to realize that for every specialty there are certain nuances they need from the IT system.”

He also contends that it’s impossible to achieve 100-percent physician satisfaction with EHR systems. “There is no one who is fully satisfied with their EHR platform. But, the bottom line is, studies show that if you improve caregiver satisfaction, then you improve patient experience and outcomes. So, the good news is that they [Allscripts] partnered with us to move in a direction to become more focused on the problem solving.”


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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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