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At iHT2-Seattle: Leadership, Culture as Keys to the Success of IT and Innovation

August 18, 2016
by Mark Hagland
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Suzanne Anderson and Sajid Ahmed offered their perspectives on the relationship between leadership and IT and organizational innovation

Technology is important, but the bottom line when it comes to success in any strategic IT endeavor really boils down to culture and leadership, two senior provider executives told their audience on August 17 at the Health IT Summit in Seattle, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC umbrella).

Suzanne Anderson, president of the Virginia Mason Health System (VMHS, Seattle), and Sajid Ahmed, chief information and innovation officer (CIIO) at the Martin Luther King Jr. Los Angeles Healthcare Corporation, both presented on topics related to leadership and innovation on Wednesday, at the Seattle Marriott Waterfront Hotel.

Anderson, who became the Virginia Mason Health System’s president on June 1, after serving as CIO and CFO of that academic medical center, spoke first, on the topic, “A Leadership Journey: Different Paths to Different Levels.”

“There are two different ways people get into senior leadership positions,” Anderson said. “One is that you take on a variety of positions and eventually are promoted. The other way is, in the IT world, you work your way up in a very technical way, through technical positions. I was CIO before president,” she said. “But am not technical. I started with a B.A. in English. So that tells you exactly how I ended up in IT, right?” she chuckled. “I got an MBA. Then I ended up in consulting. I knew that I wanted to continue to learn and move around. So I answered an ad in a paper, and joined a consulting firm. My mom was a nurse; that had been my only healthcare connection.” But, over the years, she said, she inevitably did learn a great deal about health IT, from the strategic, implementational, and process standpoints. And it was that broader understanding of systems of processes in hospital operations that led her to be a strong CIO and CFO before ascending to the president position, she emphasized; indeed, it was her strategic background and experience that led VMHS chairman and CEO Gary Kaplan, M.D. to bring her into the president role in the organization.

After asking for shows of hands from the audience of who was in technical IT positions and who wanted to ascend to organization-wide leadership positions, Anderson said that anyone who has a technical background in IT and wants to reach the CIO position or a similar position, needs to develop broader leadership and interpersonal skills, and above all must be able to convey what may be technical information, in very broadly understandable ways that can persuade diverse audiences within their organization.

Suzanne Anderson speaking at iHT2-Seattle on Wednesday

In that context, Anderson offered ten pieces of career advice. Among them, she said, “Learn to hate the interview question, ‘What do you want to be doing in five years’! I hated this!” she exclaimed. Speaking of the early years of her career, she said, “II knew I wanted to do meaningful work, but didn’t have my career path prescribed for the next 20 years. Be more flexible. I think particularly in the IT world, where our technology is changing so rapidly, that as people change careers, and as you mentor people, flexibility is so important,” she said. “I never imagined that this is where I would be, 30 years ago. But I kind of like my circuitous route,” she added.

The key point, Anderson emphasized, is that it is the broader skills that will get an individual to the higher end of the professional ladder with a patient care organization, not the technical ones. In that regard, she said, “Understand how IT fits into whatever your organizational culture is. We spend 5 or 6 percent of our budget on IT, which is a lot. So, understanding how IT fits, but also how we can balance our IT needs with the other needs of the organization”—both of those are essential capabilities of anyone moving into senior IT leadership positions in patient care organizations she said.

Indeed, in that regard, Anderson said, “This one’s really important: what gets you to a middle management role in the IT world is not what gets you to senior management overall; it’s necessary but not sufficient.” In fact, she said, “I have conversations every day with leaders who are no longer middle management, but not quite senior management. And I say, you do a great technical job; a great job getting your teams aligned, and working out budgetary issues, etc. But what I really need for you to do in this case is to think about the organization as a whole, not your area; to think about how your words are perceived by your peers, because you have to work with others on this project; and for you to really understand those more general leadership competencies. Unfortunately in IT, we’re such a technical field that this isn’t necessarily what people have been educated on, or what you’ve worked on in your career, because you’ve been rewarded for layers of technical competence,” she said.

In the end, Anderson said, some of the traits most important to senior leadership in healthcare organizations have nothing to do with more technical competence and skills. Those skill sets related to potential success in executive leadership, she said, include “people and relationships; vision with an executable plan; balancing competing priorities; and, yes, keeping calm under pressure. One of the first things I really look for in people” who might be equipped to assume senior executive roles, she said, “is how good they are in people relationships, as well as not only how much strategy they have, but how they can execute on that strategy.”

Leadership and the building of an entirely new hospital

The subject of leadership came up in a different context in the closing keynote address on Wednesday, given by Sajid Ahmed, who shared with the iHT2 audience some of the complexity of the narrative of the creation of the new Martin Luther King, Jr. Community Hospital in Los Angeles, which opened in 2015. As its description on its website notes, “The hospital serves about 1.35 million residents from all over South Los Angeles including Compton, Inglewood, Watts, Willowbrook and Lynwood. It will also create more than 1,800 jobs in the area with approximately 900 directly at the hospital.”

As Ahmed shared with his audience, “The old hospital was a critical resource for an underserved community”—and in that context, he said, “it was such a big deal to have CMS [the Centers for Medicare & Medicaid Services] say, enough, this needs to close down,” he said. But the reality, he added, was that there were so many patient care quality problems at the old facility that “Police and fire refused to send their injured officers to the old hospital.”

Sajid Ahmed speaking at iHT2-Seattle on Wednesday

So, when recruited, Ahmed told his audience, he threw himself into building an entirely new facility from the ground up; indeed, he noted, he was “employee number two”—the second executive hired to help plan and bring into existence the new MLK Community Hospital. In fact, he said, “People told me, don’t do it! It’ll kill your career. But we knew that we could do this as a new facility. We got the funding to help us do it, but our investors required us to open the hospital on time, which we did, a year ago.”

What’s more, Ahmed said, “New facilities are being built across California to meet the new seismic law requirements, but we’re unique” in creating an entirely new facility with new personnel and a revised sense of mission and purpose. And in that regard, Ahmed said, it was very important to get community input for how the new facility should be put together. So, he said, “We asked them what they needed. And it was very obvious: in the old hospital organization, care had been fragmented, and access to care had been very uneven. And from my perspective, I said, let’s see what we can do.” As a result, seven board members were identified by Los Angeles County, the state of California, and the University of California System. And those board members helped guide a process to rethink the hospital as the planning for the new facility was being created.

The new facility, Ahmed noted, is smaller in size, with a focus not only on inpatient care, but also outpatient and community-based care, and with a unique care delivery model, one that mandates that every inpatient receive case/care management beginning with their entering the hospital, and continuing through to their discharge.

Very importantly, Ahmed said, “We realized that launching the hospital and sustaining it, had to do with culture. Our biggest accomplishment will be the innovation on culture: how we work with people and with each other.”

What’s more, he said, committing to telehealth and coordinated care not only made sense for the patients at the new hospital; it also recognized the reality that hospital leaders had to thoughtfully rethink care delivery, especially given their payer mix, which is 85-percent MediCal (California’s Medicaid).

“We are in a public/private health partnership, which is unique,” Ahmed said. “And after the county gave us the money, they said, open this hospital, and then you’re on your own. We’ll contract with you for outpatient care, but you’re on your own. And we had and have unique opportunities to do telehealth. We went for it, and started using Skype to do our 5150s, with ED docs working up the patients and showing them on the screen, even though they were across the street from the inpatient hospital.”

Creating the IT infrastructure for the new hospital required collaborative planning, strategic thinking, and leadership, too, Ahmed said. “We went live with Cerner—55 modules simultaneously, and at the same time that we were hiring brand-new physicians and nurses.” In fact, he said, of the 1,000 employees hired so far, fully 300 were hired in a three-month time period prior to the new facility’s opening.

Both the IT go-live and the opening of the hospital were a big success, Ahmed said. “And now,” he said, we’re focusing on nurturing a culture of values and leadership, with collaboration and participation coming both from the bottom up and the top down.”

Was it difficult to prepare for the opening of the new hospital? Absolutely, Ahmed told his audience. “For six months, I held meetings from 6 AM until 2 in the morning. Everyone was on a different page at first. And what came out of all this was that if we didn’t do this together, we’re all going down together. And I put it out there,” he said; “I told people, you’re going to be at the top of the LA Times story.”

And the reality, Ahmed said, is that innovation can only emerge out of a specific kind of culture. “I’m a big fan of innovation,” he told his audience. “But I wanted to use that as a drive to create a culture of innovation. And part of it is not just creating new things and devices, but how to leverage processes, and improve things, especially culture.”

In the end, Ahmed said, “Trust and communication are the hardest things to do, the hardest things to build among people. Do everything you can to maintain them; that’s been part of our success. It’s not the technology’s ability to work, but the people’s ability to work the technology,” he emphasized. “Really,” he said, “it isn’t about the technology. I’m a technologist, I love technology; I launch technology initiatives. But if the doctors, nurses, and others, don’t like it, it’s not going to work.”

And, he added, “Here’s my advice. Let’s say that you’re in a meeting, or better yet, at a cocktail hour, and you’re not really paying attention to the conversation at the moment. And someone turns to you and says, ‘What did you think of that?’ when you weren’t actually listening to what the last person said. Here’s what I’d say: without having listened to what was said, you can just say, ‘It’s all about trust and communication.’ And they’ll say, ‘You’re right!’ Because it is.”


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Successful OpenNotes Implementations Require Portal Changes, More Communication

December 14, 2018
by David Raths, Contributing Editor
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Some health systems report low note-opening rates; others haven’t measured
The OpenNotes movement, in which healthcare organizations offer patients access to their clinical notes in the portal, has spread like wildfire. In just a few years it has grown to 184 confirmed health systems, with another 31 that have implemented but not documented their use, and more expressing interest every day. Yet at many healthcare organizations, the percentage of portal users reading clinical notes is still quite low, according to a new white paper and recent webinar by the nonprofit OpenNotes team.
When OpenNotes asked clinical groups for data on note-opening rates, most said it was something they did not measure, and indeed most EHR portal designs do not make it easy for them to gather that data. The OpenNotes team did collect data from 26 organizations and found that four organizations, two with homegrown EHR systems and two on Epic, had the best open rates — ranging from 21 to 34 percent, followed by eight organizations with 6 to 10 percent, with the bottom 14 reporting only 0.27 to 5 percent open rates. 
“We were stunned by the results,” said John Santa, M.D., M.P.H., OpenNotes’ director of dissemination. In many organizations, turning on OpenNotes was described as a non-event. “Sad to say that is because in some cases not much is happening,” added Santa, who played a leadership role in starting the Northwest OpenNotes Consortium and he now leads the development of future consortia. One problem is that in some cases patients are not aware of their notes or can’t find them. “Now we do know of many robust implementations where tens of thousands of patients are seeing their notes and are feeling the benefits,” Santa stressed. “But for OpenNotes to lead to best outcomes, we need to take steps to maximize the benefits.”
Their white paper notes that from the data they have gathered, “it is likely multiple factors, including portal navigation, lack of or ineffective reminders to read notes, and insufficient communication strategies contribute to low note-opening rates.”
“What we have learned is that turning it on is not sufficient,” said Cait DesRoches, DrPh, OpenNotes’ executive director and associate professor of medicine at Harvard Medical School. “Evidence suggests patients are not aware that they can read notes or they can’t find them.” Additionally, clinician anxiety around transparency is still an obstacle, she said. 
Santa noted discrepancies among customers of different EHR vendors. He said that while there are many Cerner, Allscripts and Meditech customers deploying OpenNotes, they have not developed ways to generate note-opening rates for customers. Epic, he said, has launched multiple near- and long-term changes to improve note-opening rates and included note-opening metrics in recent versions of its dashboard.
During the webinar Marcia Sparling, M.D., a rheumatologist and medical director for informatics and specialties at the Vancouver Clinic in Vancouver, Wash., made some observations about her organization’s experience. The Vancouver Clinic started piloting OpenNotes in 2014. It has a high patient portal usage rate of 82 percent, and early note-opening rates were close to 20 percent. But when the clinic did an Epic upgrade with a redesign of MyChart, the rate fell to 11 percent. “We looked at how we could help patients find the notes and why they might be missing the prompts,” Sparling said. They made a few changes. First, after-visit summaries generate an e-mail urging patients to log in, a hyperlink directs them to their past appointments page, and once there, they see wording that says “Click on your clinical notes.”
“We re-labeled that tab to ‘clinical notes’ to be more obvious,” she said. The current rate or note opening sits between 22 and 24 percent, she added, noting that there are some wide variations between specialties, although there is no obvious explanation for the disparities.
The OpenNotes white paper spells out the steps the Vancouver Clinic took to improve their note-opening rates: 
• Quick Link within MyChart patient portal (labeled ‘View clinical notes shared by your provider’); 
• Text at top of Visit Summary section directs patients to click on Clinical Notes tab; 
• MyChart home page ‘News for You’ contains paragraph on notes and a hyperlink; 
• Notes are viewable on both the Visit Summary report and the Clinical Notes tab (with some exceptions); 
• Clinicians’ notes are shared by default (with a few exceptions); 
• Auto MyChart message sent to portal user when visit is closed: Message subject reads ‘New MyChart@TVC Visit Note’; the body of message contains navigation steps and hyperlink directing patients to Appointment and Visits page.
OpenNotes is in the early stages of working with clinicians, patient groups and EHR vendors to develop metrics around use of the portal and note-opening rates. It says the definition used by Epic is reasonable as a starting point (this definition applies to notes shared over any defined time frame): Numerator = Notes listed in denominator that are viewed by a patient portal user. Denominator = Signed notes from completed encounters written on a portal active patient (or patients activated within a month of the visit) that are shared to patient portal.

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Who Isn’t Using Patient Portals? New Study Sheds Light on Portal Use

December 12, 2018
by Heather Landi, Associate Editor
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About two-thirds of adult patients did not use an online patient portal in 2017, and research indicates vulnerable and disadvantaged patients are less likely to use these technology tools, according to a study published in the November issue of Health Affairs.

Technologies such as online patient portals, which provide secure internet access to medical records and test results in addition to email communication with providers, can improve health care quality. And, evidence thus far shows that access to online portals increases patients’ engagement and adherence and may reduce unnecessary utilization and spending.

However, while the majority of adults in the United States believe that online access to personal health information is important, disparities in portal access exist.

“Findings from multiple studies that analyzed different population groups, including nationally representative samples, consistently show that members of racial and ethnic minority groups, older patients, and people of lower socioeconomic status are less likely than others to access an online portal,” the study authors wrote. The study was led by Denise Anthony, professor of health management and policy and sociology in the Department of Health Management and Policy, University of Michigan School of Public Health. Anthony and her co-authors also note that “inequities in access to new and beneficial technologies can exacerbate existing disparities in health.”

One national study, a March 2017 by the U.S. Government Accountability Office (GAO), found that only about 15 to 30 percent of patients who were offered access to a portal used it, with lower use among people living in rural and high-poverty areas.

“To identify appropriate levers that can be used to address inequities in online portal access, policy makers and providers must have a clear understanding of who is and is not accessing portals, as well as the reasons for not accessing them,” the study authors said.

For the study, titled “Who Isn’t Using Patient Portals and Why? Evidence and Implications from a National Sample of U.S. Adults,” researchers analyzed information about 2,325 insured respondents to the nationally representative 2017 Health Information National Trends survey to examine characteristics of patients who do not use portals and the reasons why they don’t them. By identifying who is not using portals and why, the researchers sought to uncover barriers and reduce disparities.

The study indicates that about two-thirds (63 percent) of insured adults with a health care visit in the previous 12 months reported not using an online patient portal. The research indicates that nonusers are more likely to be male and age 65 or older, have less than a college degree, not be employed, live in a rural location, be on Medicaid, and not have a regular provider.

These factors, along with race, were also related to whether a patient reported receiving an offer to use a portal.

Relative to females, males had significantly higher odds of not being offered access to and not using a portal, the study indicates. Members of racial minority groups (specifically, non-Hispanic blacks and non-Hispanics of other races—including Asian Americans, Native Americans, Native Hawaiians, and Pacific Islanders) had significantly greater odds of not being offered a portal. Among only those who were offered a portal, these groups reported rates of using a portal comparable to the rate of non-Hispanic whites.

The study also found that people with only a high school diploma or less were significantly less likely than those with college degrees to have been offered access to a portal. Patients with Medicaid insurance were significantly more likely to report not having been offered access to a portal and not using one, compared to people with other insurance.

Patients who lacked a regular provider were significantly more likely to report not having been offered access and not using a portal.

When evaluating reasons why people did not use a portal, the researchers did not find evidence of disparities in technological barriers. The reasons patients gave for not using portals included the desire to speak directly to providers and privacy concerns, both of which require recognition of the important role of provider communication and patient-provider relationships, the study authors note.

The study authors conclude that healthcare providers will need to address patients’ privacy and security concerns to enhance provider-patient communication.

“Reducing disparities in portal use will require that providers, particularly those serving vulnerable populations, communicate with all patients about portal use and have the capacity to discuss these technologies with patients,” the study authors wrote.

“Health care providers and plans can increase patients’ use of portals and narrow disparities in that use through direct communication about the benefits of portals, while also addressing patient-specific needs and concerns. Such interventions will require recognition that providers’ communication with patients takes time—an extremely scarce resource in clinical practice today,” the study authors concluded, while also noting that careful monitoring of who is and who is not using new technologies, and why, and designing technologies to address patients’ needs, will help ensure that such innovations do not exacerbate disparities but rather lead to improvements for all.

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AMIA, AHIMA Call for HIPAA Modernization to Support Patient Access

December 7, 2018
by Heather Landi, Associate Editor
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Modernization of the 22-year-old Health Insurance Portability and Accountability Act (HIPAA) would improve patients’ access to their health information and protect their health data in a burgeoning app ecosystem, according to two leading health IT industry groups.

During a briefing on Capitol Hill Wednesday, leaders with the American Medical Informatics Association (AMIA) and the American Health Information Management Association (AHIMA), health informatics and health information management experts discussing how federal policies are impacting patients’ ability to access and leverage their health data.

While other industries have advanced forward with digital technology and have improved individual’s access to information, and the ability to integrate and use information, such as booking travel and finding information about prices and products, healthcare has lagged. Healthcare has not been able to create a comparable patient-centric system, AMIA and AHIMA leaders attested.

“Congress has long prioritized patients’ right to access their data as a key lever to improve care, enable research, and empower patients to live healthy lifestyles,” AMIA president and CEO Douglas B. Fridsma, M.D., Ph.D., said in a statement. “But enacting these policies into regulations and translating these regulations to practice has proven more difficult than Congress imagined.”

“AHIMA’s members are most aware of patient challenges in accessing their data as they operationalize the process for access across the healthcare landscape,” AHIMA CEO Wylecia Wiggs Harris, Ph.D. said. “The language in HIPAA complicates these efforts in an electronic world.”

AMIA and AHIMA recommend that policymakers modernize HIPAA by either establishing a new term, “Health Data Set,” which includes all clinical, biomedical, and claims data maintained by a Covered Entity or Business Associate, or by revising the existing HIPAA “Designated Record Set” definition and require Certified Health IT to provide the amended DRS to patients electronically in a way that enables them to use and reuse their data.

According to AMIA and AHIMA, a new definition for “Health Data Set” would support individual HIPAA right of access and guide the future development of ONC’s Certification Program so individuals could view, download, or transmit to a third party this information electronically and access this information via application programming interface. Alternatively, a revision of the current DRS definition would provide greater clarity and predictability for providers and patients.

The groups also noted that a growing number of mHealth and health social media applications that generate, store, and use health data require attention as part of a broader conversation regarding consumer data privacy.

Congress should “extend the HIPAA individual right of access and amendment to non-HIPAA Covered Entities that manage individual health data, such as mHealth and health social media applications, the two groups said. The goal is uniformity of data access policy, regardless of covered entity, business associate, or other commercial status, the group leaders said.

Beyond HIPAA, during the briefing Wednesday, panelists discussed the success of efforts to share clinical notes with patients during visits, including the successful OpenNotes initiative, and recommended that federal officials look for ways to encourage more providers to share notes with patients through federal policies, such as Medicare and Medicaid payment programs.

“More than two decades after Congress declared access a right guaranteed by law, patients continue to face barriers,” Thomas Payne, M.D., Medical Director, IT Services, UW Medicine, said in a statement. “We need a focused look at both the technical as well as social barriers.”

What’s more, AMIA and AHIMA recommended federal regulators clarify existing regulatory guidance related to third-party legal requests, such as those by attorneys that seek information without appropriate patient-direction.

“HIM professionals continue to struggle with the existing Office for Civil Rights guidance that enables third-party attorneys to request a patient’s PHI,” Harris stated. “We recognize there are necessary circumstances in which a patient has the right and need to direct their health information to an attorney. However, AHIMA members increasingly face instances in which an attorney forwards a request for PHI on behalf of the patient but lacks the information required to validate the identity of the patient. As a result, the HIM professional is challenged as to whether to treat it as an authorization or patient access request, which has HIPAA enforcement implications

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