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VA Plans Cerner EHR Go-Live at Three Sites by 2020; Lawmakers Call for Close Project Oversight

June 27, 2018
by Heather Landi
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Cerner president Zane Burke said VA and DoD have an opportunity to lead on healthcare interoperability with EHR modernization projects
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The U.S. Department of Veterans Affairs (VA) plans to begin deployment of a new $16 billion electronic health record (EHR) system at three sites in the Pacific Northwest—Spokane, Seattle and American Lakes, all in Washington—in October 2018 with a goal of full capability by March 2020, according to VA officials.

During a House Committee on Veterans Affairs hearing Tuesday, Acting VA Secretary Peter O’Rourke updated lawmakers on the initial stages and planning for the VA EHR modernization project as the agency transitions from its aging legacy VistA system, which it’s been using for several decades, to a new Cerner EHR system.

The much-anticipated EHR modernization contract between the VA and Cerner was finally signed on May 17, after a delay of several months. A year ago, the VA announced that it would replace its aging EHR system by adopting the same platform as the U.S. Department of Defense (DoD), an EHR system from the Kansas City-based Cerner. The Cerner-VA project is a $10 billion contract, but the VA estimates that $5.8 billion will be needed for project support and infrastructure over 10 years.

“VA’s EHR modernization will be a flexible, incremental process, welcoming course corrections as we progress. Effective program management and oversight will be critical, it will be critical to cost adherence as well as to timelines, to performance quality objectives, and to effectively implement risk mitigation strategies,” O’Rourke said.

“We’ve designed a proactive and preemptive contract management strategy. We’re working closely with DoD, listening to advice from respected leaders in healthcare, and we’re fully engaged with Cerner, establishing governance boards and optimizing deployment strategy. We intend take advantage of lessons learned to mitigate risk, and strategy will adapt as we learn and technology evolves.

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In the midst of this project, President Donald Trump’s nomination to lead the VA, Robert Wilkie, has still not been confirmed; he faces a Senate confirmation hearing today. There has been tumultuous turnover among VA leadership in the past six months. Former VA Secretary David Shulkin was fired back in March and President Trump’s initial nominee, Navy Rear Adm. Ronny Jackson, withdrew his nomination amid damaging professional allegations.

O’Rourke reported to lawmakers that the VA was moving forward to establish appropriate governance and to tackle change management issues. “This is deep change, and this is a technical and cultural challenge; the human component is central to success. We’ll engage end users early to train facility staff and promote successful adoption. It’s a user-centric approach to veteran-centric change,” he said.

During the hearing, Congressional leaders voiced concerns on a number of issues and potential hurdles for the VA EHR modernization project.

Governance, Accountability and Leadership Vacancies

Committee chairman Rep. Phil Roe, M.D. (R-Tenn.) and ranking member Tim Walz (D-Minn.) announced last week the creation of a new subcommittee to focus on conducting oversight of the EHR modernization program and other technology projects at VA.

“Leadership will make or break this project, as will the oversight,” Rep. Walz said. “This panel will be a small group of three to five committee members who will focus intensively on these issues. EHR modernization is a big bet on the future of VA and we simply must make sure it succeeds.”

On the subject of governance and leadership, many committee members voiced concerns that there are still critical leadership roles that have yet to be filled, including a confirmed VA Secretary, a deputy secretary, an undersecretary for health and the CIO.

“I don’t see how this is going to end well unless we get top leadership positions in place,” Rep. Mark Takano (D-Calif.) said.

Committee members also questioned O’Rourke about media reports stating that Genevieve Morris, principal deputy national coordinator health information technology (ONC), will be leading the Electronic Health Record Modernization Program (EHRM) team. Morris was detailed to the VA earlier this year.

O’Rourke called those media reports “premature,” while acknowledging that Morris was a candidate for the position. “She has been instrumental in helping us in the past few months. She was loaned to us from HHS, and she has been critical to this team and helped us with broader perspectives of the industry and successful ways of implementing this project.”

DoD Cerner Implementation Issues

The DoD already is having issues with its Cerner implementations, according to a Pentagon report, and committee members pressed VA officials on these issues. Back in May, Politico detailed a Pentagon report which found that experts who have seen the DoD-Cerner deployments have cited highly damaging issues with that rollout, inclusive of problems so severe that they could have resulted in patient deaths. The DoD-Cerner EHR deal from 2015 is worth about $4.3 billion. 

One Congressional leader on the committee questioned O’Rourke about this report and whether it had any impact on the decision to adopt the Cerner platform. “We’re putting all eggs in one basket—every DoD and VA health record—did it give you pause?”

“We knew about implementation issues and how they have been resolved and we have integrated what we learned from them into our deployment strategy,” O’Rourke said. “We never had rose-colored glasses on; we knew that this would be an extreme challenge.”

Asked if he had any existing concerns, O’Rourke replied, “It’s cost scheduling performance, and our ability to track to the milestones that we’ve developed.”

Ashwini Zenooz, M.D., chief medical officer for the VA's EHRM program, said one of the biggest lessons learned so far from the DoD Cerner implementation has been the need to engage frontline providers early, which the VA is currently doing, she said. “Frontline providers have to be involved, and especially in the testing process. Users will be an integral component of user testing to make sure it works before go-live, to ensure patient safety,” she said.

Rep. Gus Bilirakis (R-Fla.) asked Vice Admiral Raquel Bono, director of the Defense Health Agency at DoD, to define the top challenges of the DoD EHR modernization project. “The two most challenging parts is governance and change management, and I’m gratified to see VA is working on this up front. The ability to make decisions needed at an enterprise level to maintain that interoperability and connection with VA is extremely important.” She added, “Being able to involve clinicians right from the start is an important part of the change management effort.”

Interoperability and Sunsetting VistA

During the hearing, committee members also pressed VA and DoD officials about interoperability between the Cerner systems, once implemented. Interoperability between VA and DoD has been an ongoing issue, and something that agency leaders have assured Congress will occur with the adoption of the same Cerner platform.

“Our goal is to have seamless data transference,” O’Rourke said.

Zenooz said, “A complete longitudinal record is the ultimate goal. We have learned lessons from the DoD implementation, and external implementations, and when we go live at the Cerner sites, we will have a single system that will ingest all the records, not only from DoD, but also community providers. That will include clinical notes, lab exams and radiology exams.”

On the subject of interoperability with community providers, Zenooz said, “More than 30 percent of care within VA is provided in the community. Our goal is to not only have data be available to them, but to build on it." She added that the goal is to provide the ability for providers inside and outside the VA to have the "analytics tools and registries available to them, so that they participate and improve patient outcomes.”

Zane Burke, Cerner Corporation president, also testified about the EHR modernization project, telling lawmakers that the he estimates the cost of operating the new EHR platform will be less than the current cost of $1 billion annually that is spent to operate and maintain VsitA. “Today, VistA has 100 different instances, so it requires different training and the upgrades and updates are more expensive. We believe there will be taxpayer savings over time.”

Burke also testified that, from a technical perspective, there has been progress to address the challenges around interoperability.

“There isn’t as big a challenge on interoperability today as in the past from a technical perspective, but there are still business processes within communities that create a different experience on the availability of that information. One of those challenges is who owns the personal health record. We’re offering personal health records for free, that’s ultimately one of the ways we move past those business model challenges in that space,” he testified. “It’s a complex arena, and we have spent significant time on that. We’re committed to this process.”

Burke added, “There is an opportunity for the VA and the DoD to lead in this space and I’m convinced that we have the capabilities to do that.”

One committee member also pressed VA and DoD officials on whether there would be multiple EHR systems in use. “Modernization will result in one and only one EHR system? Can you confirm that once the Cerner Millennium EHR is deployed, VA will stop using VistA and the joint legacy viewer?”

“Our intent is not to use VistA,” O’Rourke said. When asked if the Cerner EHR system will completely replace the DoD’s legacy system, Bono replied, “We will sunset the legacy system and we will maintain some connection to the legacy database, but the applications and programs, those will be sunset.”

However, David Powner, director of IT management issues at the U.S. Government Accountability Office (GAO), testified that an analysis indicates the Cerner EHR may not replace all of VistA's functionalities. He reported that an application view of VA’s health IT environment identified over 330 applications that support healthcare delivery at a VA medical center. “About 128 of these are identified as VistA applications, and 119 have similar functionality to the Cerner solution. The bottom line here is it’s important to know how much of Vista the Cerner solution will replace. Some analyses say 90 percent, but the application view suggests a much lower percentage.”

He added, “We want to avoid a situation down the road where there are surprises as to exactly what the Cerner solution is replacing.”

Powner noted that the 10-year price tag for the Cerner EHR implementation would likely be higher than $16 billion. “Given the complexity and cost, and the fact that VA healthcare and IT acquisitions and operations are both on GAO’s high-risk list, this acquisition needs to be effectively managed.”

He outlined several key factors that would be critical to the success of the program, namely, Congressional oversight, business change management, building appropriate cybersecurity measures and interagency governance, noting, “This project needs a strong CIO role.”

 


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UnitedHealth Group Plans to Unveil Health Record for Members, Providers in 2019

October 17, 2018
by Rajiv Leventhal, Managing Editor
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Health insurer UnitedHealth Group will be unveiling a “fully integrated and fully portable individual health record,” CEO David Wichmann said on the on the company’s third-quarter earnings call yesterday.

Speaking to the insurer’s broader digital health strategy, Wichmann stated on the earnings call that the company’s consumer digital health platform, Rally—which is a website and mobile app—is now serving over 20 million registered users and will leveraged to help develop the health record.

“Rally is synthesizing information and engaging people to better manage their health, helping consumers save money by selecting the highest quality care providers, understanding their out-of-pocket costs up front, and in some markets even scheduling appointments for care. We will soon be releasing at scale a first-of-kind, fully integrated and fully portable individual health record that delivers personalized next-best health actions to people and their caregivers,” Wichmann said on the call.

While many more details are not yet known about the health record, Wichmann did say that by the end of 2019, the insurance giant has the goal of developing individual health records for the 50 million fully benefited members that it serves, as well as for their care providers.

He noted, “We would use the Rally chassis…to provide individuals in a way in which they can comprehend a tool, if you will, not only outlining their individual health record, but also giving them next-best action detail. That's what I mean by when I say it's deeply personalized. It's organized around them, not based upon generic criteria. It also assesses to what extent that they've been, and how they've been served by the health system broadly, and whether or not there's been any gaps in care that have been left behind.”

Giving a little bit more information about the vision UnitedHealth Group has in regard to the health record, Wichmann said, “You might imagine what that could ultimately lead to in terms of a continuing to develop a transaction flow between the physician and us and the consumer and us, as we us being the custodian to try to drive better health outcomes for people, but also ensure that the highest level of quality is adhered to.”

UnitedHealth Group already has its Optum business line, a health innovation company that provides health services in an array of different ways, including through its growing data analytics capabilities.

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UC Davis Health’s Physician-Specific Approach to Addressing Burnout

October 16, 2018
by Rajiv Leventhal, Managing Editor
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To combat the physician burnout epidemic, one health system is taking matters into its own hands

Physician burnout has long been a significant healthcare challenge, but in recent years with the advent of various technologies into clinical workflows, along with an array of regulatory requirements, the problem seems to be getting worse.

Indeed, there is no shortage of research that backs up the notion that physicians are overburdened, with some surveys having found that 30 to 60 percent of clinicians report symptoms of burnout, which can threaten patient safety and physician health. What’s more, EHRs (electronic health records) are consistently cited as the top burnout factor, largely due to the time one must spend in them documenting and performing other administrative tasks. To this point, 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.

Although federal health officials have been outspoken about the need to combat these issues while improving physician satisfaction, some hospitals and have health systems have been taking matters into their own hands. In Sacramento, not long ago, clinical and IT leaders at the University of California, Davis (UC Davis) Health were eager to get funding to develop and roll-out a program to improve physician efficiency levels within the EHR.

Scott MacDonald, M.D., the health system’s EHR medical director, says that in order to get that funding, his team needed to show the organization’s leadership, via a pilot project, that a program designed around improving physician efficiency in the EHR was worthwhile and valuable. They ended up getting a small team together, mostly volunteers from various UC Davis Health locations, and piloted two high performing clinics and two low performing ones, based on efficiency data from Epic, MacDonald recalls.

In order to determine which clinics were doing well with their EHRs, and which ones were not, the UC Davis Health team looked at a number of factors. For one, they would examine a given individual physician to see if he or she was spending more than the average amount of time on certain EHR “in-basket” tasks, explains MacDonald. “We would then look and compare that data to others in that physician’s department and specialty to see if there were outliers. So that’s a useful tool for us to recognize that this person is efficient with chart reviews but inefficient with writing notes, [for example].”

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MacDonald says that they would also survey the physicians to see what they personally feel they are most inefficient with in the EHR. “We wanted to make sure that we address their biggest areas of frustration,” he says, noting that the organization is also looking to add a chief wellness officer to help accomplish this.

Problems in the Trenches

MacDonald says that his team, based on anecdotal conversations with physicians, believes that it’s “patently obvious that doctors are frustrated by EHRs and IT, as well as the other factors from the changes in the healthcare system over the last few years, as well as the regulatory environment.”

That said, MacDonald doesn’t believe that EHRs are hurting the physician-patient relationship; more so that they are “blamed” for hurting it. “Because of what’s happened over the course of the last decade, with lots of regulatory requirements, even going back to the 1990s with CMS [the Centers for Medicare & Medicaid Services] billing regulations, all those things have been addressed in a lot of organizations through the EHR. So people tend to shoot the messenger and blame the EHR for these ills. But the EHR is really just a tool, and if that tool is built and trained well, it’s certainly a real boon to the quality of care we deliver,” he says. “If people know how to use the tool effectively when they are seeing a patient, [it will] become a partner in the care with the patient, rather than a mediator of the care,” he emphasizes.

Providing some more context, MacDonald believes that if doctors have the computer screen up between them and the patient, and all the patient sees are the wires coming out of the back of the monitor, that doesn’t make for a good experience for the patient. “But if you are in a triangle with the patient and the monitor, and you are engaging the patient in the data you are looking at, then it could be a real positive. Across the U.S., we have not trained our physicians in that aspect of modern medicine. How we use the tool is part of the relationship with the patient,” he says.

A Program Designed for the Physician

UC Davis Health’s Physician Efficiency Program (PEP), modeled after the pilot project in the four clinics last year, tapped program manager Melissa Jost, who oversees six analysts. Teams of three are deployed to clinics to train and build features within the Epic EHR platform. What’s more, Jost supervises two builders and four trainers, an approach that MacDonald believes makes this program particularly unique. “We integrate the building and training in one team. So when we go out to the clinics and work with [physicians], we can not only show them how to use the tools that exist, but also build the tools if one doesn’t exist and there is something that is workflow-specific that’s needed.”

Each team spends up to six weeks in a clinic monitoring workflows, reviewing EHR-use metrics and working one-on-one with each physician to personalize and optimize their use of EHR tools. Clinics also reduce each physician’s patient schedule by 50 percent to allow time for the training sessions right in the clinic during normal clinic hours, with team members also available for follow-up questions or sessions on site, according to officials, who also note that the goal is to engage all primary and specialty care ambulatory physicians by 2020.

MacDonald admits that to date, the data isn’t perfect, but it gives his team broad strokes about how effective individuals, clinics and groups are using the EHR system. Nonetheless, officials point to some encouraging results from the program—namely a 12-percent increase in physician satisfaction, 24-percent increase in physician efficiency, and an average reduction of 25 hours less per month in time spent working after hours per physician trained.

And in terms of anecdotal physician feedback, MacDonald says that they love the program so far. “We have been getting rave reviews,” he notes, noting that he recently asked physicians at one clinic their feelings about the program and how it can improve, to which the near universal response was, “When are you coming back?”

When asked if physicians feel that the core problem with EHRs is the documentation requirements, or technical flaws in the systems themselves, MacDonald chalks it up to a “mix of everything.” He says that this type of tension is common in informatics, and people ask, “Why can’t Epic just do [X]?” But MacDonald notes that oftentimes the system actually can do that thing and the physician might not know how to do it. “Often, people’s frustrations can be easily met with simple training because the tools are already there from the vendor. But that’s not always the case, and that’s why we do additional build work to customize it,” he says.

MacDonald adds that in healthcare, there is always this “undercurrent of external requirements that don’t appear to people to have much clinical value,” such as reporting on quality measures, data collection, and regulatory requirements, but most physicians do reluctantly accept the necessity of these things by working in the modern healthcare system. “But if we can mitigate [the burden] by giving them a faster way of doing it, they will appreciate it,” he says.

 


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Report: athenahealth Has Multiple Bidders for Sale of the Company

October 15, 2018
by Heather Landi, Associate Editor
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Watertown, Mass.-based health IT company athenahealth has attracted interest from at least five potential bidders for a possible sale of the company, people familiar with the matter told Bloomberg.

In an article posted Friday, Bloomberg reports that private equity players including Bain Capital, Hellman & Friedman, Clayton, Dubiliar & Rice and TPG are considering bids for athenahealth, the people said, asking not to be identified because the matter is private. Elliott Management Corp., the sometimes-activist fund run by billionaire Paul Singer, is also weighing a bid, people familiar with the matter told Bloomberg.

Elliott, which owns 9 percent of athenahealth, may keep that stake if it is unsuccessful in acquiring the company, the people said.

“athenahealth has received indications of interest above $135 a share, the people said, with final bids due by the end of the month,” Bloomberg reported.

As previously reported by Healthcare Informatics, in May, Elliott Management made an all-cash takeover offer to buy athenahealth, at a valuation of $6.9 billion. The investors sent a letter to athenahealth’s board proposing to acquire the company for $160 per share. In the letter, the investors criticized leadership at the electronic health record (EHR) vendor for failing to make the changes necessary “to enable it to grow as it should and to create the kind of value its shareholders deserve.”

The story continued to take turns throughout the summer, particularly following the resignation of CEO and President Jonathan Bush in June. Bush’s resignation came just a few weeks after Elliott Management’s takeover bid, and just a few days after reports surfaced that the athenahealth chief had allegedly assaulted his ex-wife more than a decade ago, and also created a “sexually hostile environment” at the company.   

Following the news, various companies, both inside and outside of healthcare, were brought up as possibilities to buy athenahealth, including the Kansas City-based EHR giant Cerner Corp.

According to a report in the New York Post published in early September, Elliott Management was cited as the favorite to win the athenahealth takeover bid, reporting that Cerner and UnitedHealth declined an opportunity to acquire the health IT company.

The Sept. 6 report noted that “The healthcare companies that would most logically be interested in athenahealth, including Cerner Corp. and UnitedHealthcare, have taken a pass…” As such, Elliott has now teamed up with investment firm Bain Capital on its bid, the New York Post noted at the time.

Bain Capital owns Waystar, a healthcare technology company that was recently formed by combining Navicure and ZirMed, two revenue cycle management vendors. Waystar may benefit if Bain buys athenahealth, an industry banker told the New York Post.

However, almost two weeks later, another report in the New York Post indicated that Elliott Management had backed away from its $160-a-share bid for athenahealth. “As a result of Singer’s retreat and the lack of robust interest from others, athena has extended a final bid deadline by 10 days — to Sept. 27, sources said. Singer backing off the promised bid is a stark turnaround in the battle for the health care tech company,” the New York Post article stated.

According to an October 11 article in the New York Post, suitors whose offers were deemed too low months ago are being invited to take a second look, according to sources. Bids are now believed to value the company at no greater than $135 a share.

“athena first sought final bids by a Sept. 17 deadline. Then, it extended that deadline by 10 days. Now, the company will likely not make a decision until next week at the earliest on how to proceed, two sources said,” according to the article.

“The seller is deciding between a full sale, a merger with Pamplona Capital’s NThrive or to continue as a listed company,” the New York Post article reported.

The New York Post article also reports that if the company decides not to sell or merge, it will have to find a new CEO to replace Bush, sources said. Former GE chief Jeff Immelt has been running Athena as its executive chairman since the summer.

“They definitely need a CEO that is not Jeff Immelt,” the analyst said in the article. “If I’m the candidate, I would want to know what Elliott’s perspective is going forward.”

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