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VA Asks Congress for $782 Million Funding Fix to Kick Off Cerner EHR Implementation

November 15, 2017
by Heather Landi
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During a House Appropriations Military Construction and Veterans Affairs subcommittee meeting Wednesday, VA Secretary David Shulkin, M.D., said the department is facing a “time crunch” and wants to jumpstart its work to implement a Cerner electronic health record (EHR) system in order to align its EHR deployment with the U.S. Department of Defense (DoD).

The VA is requesting Congress to reprogram almost $800 million ($782 million) from its current budget to get started on the work to replace its aging homegrown EHR system with the Cerner EHR in order to achieve cost savings, and also avoid a longer implementation. Essentially, Shulkin said VA needed the funding by the end of the calendar year to achieve efficiencies to align closely with the DoD’s current multi-billion-dollar Cerner implementation.

“We prefer to fund the plan as part of the enacted 2018 appropriations bill. However, we have to do this quickly, as we have achieved substantial discounts by aligning our EHR deployment and implementation with DoD. In absence of an appropriations bill by end of the year funding the plan, we ask Congress to consider approving the transfer request, so we can promptly award the contract,” Shulkin said during the subcommittee hearing. “This continency allows us to avoid cost increases and to move forward with IT infrastructure modifications and expand our program management office to provide necessary oversight and manage implementation.”

Recently, the House Appropriations Committee cleared the fiscal year 2018 Military Construction and Veterans Affairs Appropriations bill, which included $65 million for the modernization of the VA EHR system—for year one alone. Some media reports have estimated that the cost of the entire project could be as much as $18 billion.

Shulkin told lawmakers on Wednesday that failure to obtain the funds and to get started on the work would mean missing a window to align its work with the DoD’s current roll out of its Cerner EHR and would drive up the project’s costs by about 5 percent over the 10-year project.

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Ranking Member Debbie Wasserman Schultz, (D-Fla.) said during the hearing, “It’s frustrating that the VA’s foot dragging and missteps have become our emergency.”

Wasserman Schultz also voiced frustrations about the long history of failed attempts to modernize the VA’s EHR and build interoperability between the VA and the DoD, including an effort to create a single EHR for both agencies back in 2011. That effort fell apart two years later, despite spending nearly $1 billion. At that time, the VA chose to modernize its aging EHR system, the Veterans Health Information Systems and Technology Architecture, called VistA, while the DoD chose to implement a commercial, off-the-shelf EHR system.

This past June, the VA announced its plan to replace VistA with the Cerner Millennium EHR system, which the DoD is already implementing. In the announcement, VA cited the need to achieve seamless interoperability with DoD and a desire to reallocate resources away from in-house software development and back into core functions of VA.

“I’m pleased VA is moving in the direction of an integrated EHR system with DoD. I was not pleased with getting a $782 million reprogramming request at end of October, which needs to be acted on by November, with no details concerning how the system will work with private sector providers. Veterans are taking advantage of community care and we need to ensure that new EHR system can seamlessly exchange data with the private sector,” Wasserman Schultz said, adding, “Years down the road, I hope not to be in a hearing where we’re discussing our frustration over the less than complete interoperability and ability to seamlessly move electronic health records from DoD and military service to the private sector.”

During the hearing, Shulkin testified, as he has said in previous hearings, that the VA intends to award a 10-year contract to Cerner with plans, once the contract is signed, to have the EHR implemented at the first site in 18 months, followed by a seven- to eight-year roll out to get the EHR fully implemented throughout the VA.

“We have to implement much faster and more aggressively than DoD because, looking at the number of facilities we have, we have two-thirds more than DoD,” Shulkin said.

Shulkin said DoD leaders are sharing lessons learned and implementation plans which helps to create efficiencies in the VA’s roll out. However, the noted, “The DoD is one third the size of VA. Ours is a much more complex and larger implementation.”

The VA’s new EHR has to be rolled out to the VA’s 1,600 facilities and the VA intends to run VistA in parallel with the new Cerner system and will be shutting down the 130 instances of its current EHR, over time, until full implementation in 10 years, Shulkin said.

Lawmakers voiced concerns about the timeline and costs for the project, given the VA’s history of spending time and money on IT modernization projects yet the VA and DoD have yet to achieve interoperability.

Shulkin said the VA was tackling the project in a different way than previous VA IT projects. “The VA does not have a great history of being on time, on cost. But, first of all, we’ve given up on the idea that we’re going to be doing software development ourselves. By buying commercial off the shelf, we’re relying on industry partners with good track records. Secondly, we’re going to do the governance on this project, and the oversight on this project directly out of the Secretary’s office. The root cause of problems with VA has been the silos between IT and the health system,” Shulkin said, noting the creation of a governance committee comprised of both Veterans Health Administration and IT leaders.

What’s more, Scott Blackburn, executive in charge of the VA’s Office of Information and Technology, said he was in the process of speakign with private sector healthcare CIOs in order to gather input and recommendations about the VA’s EHR contract with Cerner and project implementation.

John Windom, program executive for electronic health record modernization at the VA, said, “We intend to align efforts to those of DoD today. We’re leveraging the lessons learned that DoD has in their associated deployment challenges. That critical alignment early in the process allows us to move out more aggressively in our approach to be more efficient in our approach and again to maintain the configuration management over both sides, the VA and DoD, and to support seamless information exchange,” Windom said.

Windom told lawmakers that the VA planned to start its EHR roll out in the Pacific Northwest, to align with DoD’s current work. The DoD rolled out its Military Health System (MHS) Genesis EHR system at Madigan Army Medical Center in Takoma, Washington in October. Madigan is the fourth military site to go live with the Cerner EHR, and that follows installations at Fairchild Air Force Base, Naval Health Clinic Oak Harbor and Naval Hospital Bremerton.

“Our intent is to deploy to the Pacific Northwest and there are economies of scale to be gained by labor efficiencies. By us deploying into the same geographical area, we’ll be able to leverage the resources that are already in that area,” Windom said.

Shulkin and other VA leaders did not disclose more details about total project costs during the public hearing, but a closed-door hearing with lawmakers followed the public hearing.

Shulkin also explained the complexities of the project to replace VistA with Cerner’s Millennium EHR. “VistA, by itself, is not a system; it’s 130 different instances of an EHR,” he said, also telling lawmakers that upgrading VistA to industry standards would cost $19 billion over 10 years.

Rep. Scott Taylor (R-Va.) wanted assurances from VA leaders that, once the project is completed, the VA and DoD will have “100 percent) interoperability.

Windom responded, “We will be on the same Cerner Millennium platform, hosting our data in the same hosting facility, so we will communicate seamlessly across the VA and DOD environments.”

“I’m convinced that being on the same EHR as DoD is the best solution. It will allow VA to keep pace with health information technology and cybersecurity improvements that VistA can’t achieve. Veterans’ health information will reside in a single common system to provide seamless care and we will be able to share veterans’ health information with community partners,” Shulkin said.


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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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