Can EHR Data Identify Patients Who May Be Falling Through the Cracks of Your Healthcare System? | David Raths | Healthcare Blogs Skip to content Skip to navigation

Can EHR Data Identify Patients Who May Be Falling Through the Cracks of Your Healthcare System?

August 5, 2016
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Researchers describe challenges to patient safety improvement efforts

We hear lots of talk about the potential of big data and learning health systems, but for those to become more than buzzwords, health systems have to devote more resources to using their clinical data for process improvement and patient safety research.

I had the opportunity this week to interview two patient safety researchers from the Michael E. DeBakey VA Medical Center in Houston: Hardeep Singh, M.D., M.P.H., chief of the Health Policy, Quality & Informatics Program in the Center for Innovations in Quality, Effectiveness and Safety, and Elise Russo, the center’s research coordinator. They were among the co-authors of a paper just published online titled, “Challenges in patient safety improvement research in the era of electronic health records.” 

As they explained to me, their earlier work in the VA system had been to study diagnostic errors and cases where abnormal test results get lost in follow-up.

“We have used EHR data in order to identify patients who may be falling through the cracks of the healthcare system,” Singh said. So if a patient goes to primary care and then gets admitted to the hospital unexpectedly within 10 days, they look for patients who may have had a diagnostic error on the first visit. They call these trigger algorithms. The second example is more like a prospective trigger — when someone has an abnormal test result, and you would expect that to be followed up on, but it doesn’t happen. They might have a chest x-ray that shows a nodule in the chest. “At the VA, we code the data so it is already flagged,” Singh said. “If you don’t see a CT scan within 30 days, or a bronchoscopy or biopsy within 30 days, the computer knows that there is no action, that can get flagged. We have used longitudinal data to look for diagnostic and follow-up errors.”

“The work we have done is in research mode,” he added, “but we are trying to operationalize it within the VA, and hopefully one day outside the VA as well.”

The paper they wrote described their efforts to do similar patient safety research in three health systems outside the VA using other commercial EHRs, including Epic. But they found several roadblocks, including at the policy level, a lack of structured data, and in working with IT staff.

In their paper they noted that researchers must be able to access and review EHR data to conduct patient safety research. “However, we found superfluous restrictions on remote data access for researchers. This was best illustrated at Site A, where the organization's internal research oversight team would not provide approval for remote access to the organization's EHR despite approval by the local institutional review board (IRB).”

“As outside researchers, we encountered a lot of these problems,” Russo said. “Security was the major concern we encountered. We figured that since we had IRB approval, they should let us access what we have approvals for. But at pretty much every site, that was not the case, even when we had approvals. There was always something blocking us, including rules that we had to have an employee of the institution on our team to help with chart reviews. Obviously a lot of this was related to their fears about data breaches.”

Lack of structured data

Singh said the lack of structured data they encountered was “a bit of a shock to us.” As they wrote in their paper, the sites had variable amounts of structured EHR data (i.e., lack of “normal” or “abnormal” codes for test results), and “often the same field was structured at one site and unstructured at another site, making cross-site automated comparisons difficult or impossible.”  All three sites met Stage 1 Meaningful Use requirements. “However, at all three sites we were informed by IT staff that there was no method for the computer to automatically identify significantly abnormal radiology, pathology, microbiology, and certain clinical laboratory results,” they wrote.

 “Our point is if you are going to collect all this data electronically, you have to structure which lab is abnormal,” Singh said. “Some of the structure has to be around abnormal stuff, so you can look for it,” he said.

IT personnel issues

Despite clinical leadership buy-in, the patient safety researchers reported experiencing barriers to working with IT personnel because of their competing operational priorities at all three sites. “We found that organizational IT personnel at all sites were significantly resource-constrained and had many competing priorities, particularly related to MU implementation and EHR upgrade-related issues. This resulted in delays in understanding several data-related issues and in getting EHR queries operationalized,” they wrote.

In the “key lessons” section of their paper, they suggest that “all organizations (not just those with “research” as part of their mission) should dedicate additional IT personnel and implement near real-time clinical data warehouses with easy-to-use report writing capabilities to support quality improvement and patient safety improvement efforts. This would allow current IT staff to focus on operational activities. Unfortunately, our experiences reveal that the IT workforce for health care is often ill-prepared, lacks the necessary tools and resources, and is deficient in the clinical and workflow insights and experience necessary to address both research and non-research tasks related to extraction and analysis of EHR data.”

“Organizations need to think about how to build that IT personnel infrastructure to do some of this work,” Singh told me. “We hear that big data is going to change everything, but we are still struggling to get the basics right. Very few institutions are using electronic data at a progressive scale to make improvements. What we need to do is have models of how to take electronic data, learn from it and make improvements.”

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/news-item/ehr/allscripts-sells-its-netsmart-stake-gi-partners-ta-associates

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.

Webinar

Driving Success at Regional Health: Approaches and Challenges to Optimizing and Utilizing Real-Time Support

Regional Health knew providing leading EHR technology was not the only factor to be considered when looking to achieve successful adoption, clinician and patient satisfaction, and ultimately value...

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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