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VA, Cerner Leaders Detail Progress on EHR Implementation, Interoperability Efforts

November 14, 2018
by Heather Landi, Associate Editor
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The U.S. Department of Veterans Affairs (VA)’s new $16-billion-dollar Cerner electronic health record (EHR) system will use open application programming interface (APIs) and Fast Healthcare Interoperability Resources (FHIR) standards to enable interoperability with the private sector, according to a Cerner executive, which potentially positions the VA as a leading force to drive interoperability forward in the healthcare industry.

The ability of the VA’s healthcare system to seamlessly share patient data with the U.S. Department of Defense (DoD) as well as health systems and physicians in the private sector continues to be a top concern among Congressional leaders as the VA is now six months in to its implementation of a new Cerner EHR, and the topic dominated a House oversight subcommittee hearing on Wednesday.

Congressional leaders pointed out that interoperability between VA and DoD and between VA and community providers would be key to the success of the VA electronic health record (EHR) modernization effort. “If you can’t make that step work, then this won’t work,” Rep. Phil Roe, M.D., (R-Tenn.) chairman of the House Veterans Affairs committee, said.

During the hearing, members of the House Veterans Affairs' technology modernization subcommittee reviewed the electronic health record modernization (EHRM) program’s accomplishments, to date, and questioned VA and Cerner leaders about implementation planning, strategic alignment with the DoD’s MHS Genesis project, as DoD also is rolling out a new Cerner EHR, as well as interoperability efforts.  

The VA signed its $10 billion contract with Cerner in May to replace VA’s 40-year-old legacy health information system—the Veterans Health Information Systems and Technology Architecture (VistA)—over the next 10 years with the new Cerner system, which is in the pilot phase at DoD. The VA project will begin with a set of test sites in the Pacific Northwest in March 2020.

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In October, the U.S. Secretaries of the VA and DoD signaled their commitment to achieving interoperability between the two agencies by implementing a single, seamlessly integrated EHR, according to a joint statement both agencies issued. VA Secretary Robert Wilkie and Defense Secretary James N. Mattis signed a joint statement Sept. 26 pledging that their two departments will “align their plans, strategies and structures as they roll out a EHR system that will allow VA and DoD to share patient data seamlessly."

However, subcommittee chairman Jim Banks (R-Ind.) noted during the hearing, “Community provider interoperability has always been the elephant in the room. VA-DoD interoperability is very important, but VA is further behind in exchanging records with its community partners. There are helpful tools, such as health information exchanges (HIEs), but no out-of-the-box EHR system completely solves this problem.” Banks added, “Community interoperability is a very real problem, and for $16 billion, VA had better solve it.”

It is estimated that up to a third of VA patients receive care in the private sector.

"I’m not ready to sound the alarm, but I’ve heard very little on the subject [interoperability with DoD and community providers],” Banks said, noting that a review by industry experts indicated that VA and DoD need to be on the same instance of the Cerner EHR in order to achieve seamless interoperability. “That means both departments have to pull patient data from the same database. The two implementations have to be joined at the hip. It raises the stakes. It’s important to put this reality out in the open, and early.”

During her testimony, Laura Kroupa, M.D., acting chief medical officer with the VA’s Office of Electronic Health Record Modernization (OEHRM), noted that interoperability with community healthcare providers was a challenge that VA and Cerner leaders were working together to address.  “Going on the Cerner platform will allow us to utilize national systems in place for interoperability. Our community care councils also look at all the different workflows for how patients get referred into and out of the VA to make sure that information is exchanged and put into the system, not just as a piece of paper or image, but actually the data itself,” she said. Kroupa said project leaders are working to utilize interoperability mechanisms that Cerner currently has as well as HIE initiatives already in place, such as Carequality and CommonWell, to ensure interoperability between VA and the private sector.

John Windom, who leads the VA’s EHR modernization project as the executive director of VA’s OEHRM program, said, “There are two issues—one is technology-based which is solved, the HIEs, CommonWell, Carequality, allow seamless exchange of information. But, there is also another piece, the information has to be put in, and so that information has to be made accessible by the people on those networks; we’ve got the technology piece solved.”

Travis Dalton, president of government services at Cerner, testified that Cerner would use open APIs and FHIR-based integration to enable interoperability between VA and healthcare providers in the private sector.

“We’ve committed to that contractually. It’s going to happen, it’s technically possible and feasible,” Dalton said, adding, “What will be powerful to the industry and commercial partners is if VA and DoD choose a common standard. That will move the industry forward because this isn’t always a technical issue, it’s a standard-based issue. The power of the DoD and VA to make that choice to move it forward will influence the commercial marketplaces. The tools exist, through HIE and Direct exchange; it’s a standards issue.”

Congress created the technology modernization comittee to provide more rigorous oversight of the project amid concerns about the project’s cost and alignment with the defense department’s electronic health record roll-out.

There have been ongoing questions about VA leadership, specifically with regard to the EHR modernization project, beginning with the ouster of the previous VA Secretary, David Shulkin, M.D., earlier this year, as well as other shake-ups, including the resignation of Genevieve Morris only two months after she was tapped to lead the VA’s EHR project.

An investigation by ProPublica, detailed in a report published Nov. 1, asserts that VA’s EHR contract with Cerner has been plagued by multiple roadblocks during the past year, including personnel issues and changing expectations. According to that report, Cerner rated its EHR project with the VA at alert level "yellow trending towards red.” To investigate the underlying factors that have contributed to the EHR project's problems, the publication reviewed internal documents and conducted interviews with current and former VA officials, congressional staff and outside experts.

In parallel, Rep. Banks has expressed concerns with the VA’s “apparent loss of focus” on innovation, specifically as it relates to open APIs. In a letter to acting VA Deputy Secretary James Byrne dated Oct. 10, Banks noted that two years ago the VA initiated an open-API gateway interoperability platform concept, called Lighthouse. Back in March, during the HIMSS Conference, the VA also announced an open API pledge, with the launch of a “beta” version of its Lighthouse Lab, which offers software developers access to tools for creating mobile and web applications to help veterans better manage their care, services and benefits. Banks wrote that these efforts seem to have “lost momentum.”

In the letter, Banks noted that the VA needs a flexible platform to translate data coming in from multiple EHRs and on which to build, and so its private sector partners can build, interfaces to and from medical practice billing systems, insurance companies, external applications, veterans’ devices and one day Medicare and Tricare’s systems. “The need to ‘future-proof’ the technology that VA is acquiring is very real. Moving forward with the open-API gateway and sustaining the open API pledge are important steps to do that,” Banks wrote.

Progress Made in the First 180 Days

During the hearing, Windom outlined the EHRM program’s accomplishments, to date, including the establishment of 18 workflow councils and current state assessments of the initial implementation sites. VA and Cerner project leaders also completed an analysis report to assess the DoD’s MHS Genesis system as EHRM’s baseline. The workflow councils are mostly comprised of clinicians in the field who provide input to enable configuration of national standardized clinical and operational workflows for the VA's Cerner EHR system, Windom said.

Dalton said the site visits of the initial implementation sites provided important insights into VA’s IT needs. “VA has a unique patient population, you’ve got an older, sicker population, with unique needs, such as behavioral health. Some areas that we uncovered that we need to focus on now include telehealth, behavioral health and reporting. These are big content areas,” he said, adding, “I expect the work that we do will help to lead us into the future in that area. We expect that as we work closely together to meet the needs of the agency that will help to makes us better commercially.”

Dalton said the VA Cerner are committed to applying commercial best practices, as well as any lessons learned from our DoD experience, to the VA’s EHRM program.

“We learned some hard lessons with the DoD experience,” he said. “Transformation is always difficult. We’re doing things a lot differently—we’re engaging with sites early and often. We’re also doing more workshops up front, so it’s more of an iterative process.” And, he added, “This is a provider-led process. We have the 18 councils that are assisting us with validation of the workflow.”

 


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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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