The “Point-Counterpoint” to End All Point-Counterpoints in the Healthcare IT Policy World? | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

The “Point-Counterpoint” to End All Point-Counterpoints in the Healthcare IT Policy World?

September 12, 2017
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The New England Journal’s op-ed face-off offers a surprising level of conceptual overlap

The New England Journal of Medicine, long known for providing a forum for the discussion of complex and thorny healthcare policy issues, has surpassed itself in its latest issue, dated September 7, by showcasing what might be the ultimate point-counterpoint of contrasting views of the meaningful use program under the HITECH (Health Information Technology for Economic and Clinical Health) Act.

In last week’s issue, the esteemed NEJM published facing Perspectives (op-ed articles) by, on the one hand, a team of the four most recent past National Coordinators for Health Information Technology; and on the other hand, two exceptionally well-known national healthcare IT leaders. Thus, on p. 904 began “The HITECH Era and the Path Forward,” authored by Vindell Washington, M.D., Karen DeSalvo, M.D., Farzad Mostashari, M.D., and David Blumenthal, M.D.; and beginning on p. 907, readers were offered “The HITECH Era in Retrospect,” authored by John D. Halamka, M.D., CIO of Beth Israel Deaconess Hospital in Boston, and Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative.

This face-off of healthcare IT policy titans did not disappoint. On the one hand, the two teams did present somewhat contrasting perspectives on the meaningful use program; on the other hand, there was a surprising level of consensus on some of the fundamentals, as well as on some of the particulars, in their arguments. Let’s look at both, and then analyze the confluence of perspectives.

First, Drs. Washington, DeSalvo, Mostashari, and Blumenthal provided a broad overview of the history of the meaningful use program under HITECH. There’s no need to reproduce that summary here in full, though certain passages are worth quoting.

For one thing, the former National Coordinators note, eight-and-a-half years after the Congress passed, and President Obama signed, the HITECH Act, as part of the ARRA (American Recovery and Reinvestment Act of 2009), “Today, almost all U.S. hospitals and nearly 80 percent of office-based practices use certified EHRs [electronic health records]. A majority of providers can share health information between systems, and 87% of patients report having access to their electronic health information. More important, of nearly 500 studies examining the use of health IT functionalities required for what the HITECH Act designated as “meaningful use,” 84 percent showed that deploying this technology had a positive or partially positive effect on care quality, safety, and efficiency.”

Still, the National Coordinators write, “Obstacles emerged with the rapid deployment of technology and the development of new sources and uses of health data. Primary policy goals were to foster health IT adoption and stimulate the economy. The ONC [Office of the National Coordinator for Health IT], for example, was originally structured as a coordinating entity rather than a regulatory agency, and HITECH only slightly adjusted that profile. Participation in the EHR incentive program and the vendor-certification program is voluntary. Other challenges included congressional expectations of rapid allocation of HITECH funds and development of IT programs. A short timeline meant that some organizations simply expanded existing, proprietary EHRs; the design was hampered as clinical documentation requirements were in competition with billing and compliance needs.”

Importantly, the former National Coordinators concede, “Health care providers, especially physicians, have borne the brunt of this transformation. Many are frustrated by poor EHR usability and the lack of actionable information generated by these systems. In part, such limitations are attributable to the decision to allow proprietary standards and data blocking in the market, which has led to suboptimal data sharing.” So what’s the answer? “As former national coordinators for health IT,” they write, “we believe that the culture surrounding access to and sharing of information must change to promote the seamless, secure flow of electronic information. Both patients and providers want health information to be sharable between systems. Relevant policy work has involved educating clinicians, technology developers, and patients about common misperceptions associated with privacy protections under the Health Insurance Portability and Accountability Act (HIPAA). It has also focused on empowering patients through efforts such as the Blue Button Initiative, which allows patients to view and download their personal health information.”

And the former National Coordinators spend nearly the entirety of the rest of their op-ed article promoting the idea of interoperability, in the context of internal healthcare system reform. One of the main goals they see is this one: “Health IT provides new opportunities to engage patients and caregivers and can empower patients to learn and communicate more easily about their health, engage in shared decision making, and manage their care in convenient and meaningful ways. Market innovations and government policies should soon allow patients to combine information from various sources to create a single resource with all their current and historical health information. Seamless interoperability,” they emphasize, will facilitate better monitoring of health outcomes, as well as efficient resource use and cost analysis, particularly for care provided in multiple systems and settings. An emerging public health model, Public Health 3.0, encourages various sectors to collaborate to use data to enhance the societal effects of public health efforts.” They also see interoperability as vital to efforts to create a “learning health system.”

Halamka and Tripathi Weigh In

Interestingly, John Halamka and Micky Tripathi agree with the former National Coordinators on some key points. For one thing, they begin their op-ed by stating that, “At a high level, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 accomplished something miraculous: the vast majority of U.S. hospitals and physicians are now active users of electronic health record (EHR) systems. No other sector of the U.S. economy of similar size (one sixth of the gross domestic product) and complexity (more than 5000 hospitals and more than 500,000 physicians) has undergone such rapid computerization.” That said, they immediately add that, “Along the way, however, we lost the hearts and minds of clinicians. We overwhelmed them with confusing layers of regulations. We tried to drive cultural change with legislation. We expected interoperability without first building the enabling tools. In a sense, we gave clinicians suboptimal cars, didn’t build roads, and then blamed them for not driving.”

The chief culprit, in their view? “Burdensome requirements imposed costs on providers and vendors without offering sustained benefit. These deficiencies were manifested in five key areas: usability, workflow, innovation, interoperability, and patient engagement.”

Not only that; Halamka and Tripathi “name names.” “The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) set ambitious requirements for ‘meaningful use’ of health information technology (IT) to ensure that Medicare and Medicaid would get value from their large investment on a fixed timeline,” they write. “But in the absence of business and clinical drivers for change (HITECH predated the Affordable Care Act by more than a year), meaningful use came to be used as a de facto vehicle for transforming health care delivery — a purpose for which, as a technology investment program, it was not adequate.”

The industry leaders go on to pillory the “avalanche of requirements” foisted upon clinicians in practice. And, importantly, they opine that, “Furthermore, meaningful use set unrealistic expectations for interoperability. Though it did not specify a nationwide patient-matching strategy, create a nationwide directory of provider electronic addresses, forge a single set of consent or privacy guidelines, or define governance for deciding who could exchange what for various purposes, it set requirements with the assumption that interoperability could somehow skip over such essentials.” They further contend that, “Instead of recognizing the work that needed to be done on these foundational items, some policymakers invented the myth of “information blocking” as the root cause for lack of data flow. Our 50-plus combined years in the health IT industry have taught us that when technology, policy, and business needs are aligned, data flow.”

Still, even with that, Halamka and Tripathi acknowledge that “HITECH has played an invaluable role in accelerating the adoption of EHRs throughout the country.” What’s next? “We believe that now is the time to step back and recalibrate the role of the federal government on the basis of lessons learned,” they write. And they believe that a few major policy shifts need to take place: “First, requirements related to meaningful use and the Merit-Based Incentive Payment System (MIPS) introduced by CMS could be dramatically simplified to focus on interoperability and a streamlined set of outcome-oriented quality measures. Second, EHR certification could focus exclusively on interoperability capabilities by setting up a public test server and reporting on EHR vendors’ success in reading and writing medical records on it.” And, “Third, interoperability could be encouraged by market action rather than by regulation. The ONC… and other federal agencies could actively encourage private-sector networks to connect with each other using open industry standards, much as wireless and automated-teller networks have done. Finally, we could offer incentives for the adoption of open industry application programming interface (API) standards, such as FHIR, for provider–patient, provider–provider, provider–payer, and payer–patient interactions.”

Some Points of Commonality

So what’s interesting here? What to me is the most interesting is that the Halamka/Tripathi team is not necessarily that far apart from the former National Coordinators in their broader perspective, in certain respects. Everyone agrees that interoperability needs to be the biggest focus of federal healthcare IT policy going forward. What’s especially interesting is that Donald Rucker, M.D., the new National Coordinator, shared his strong interest in market-driven interoperability progress, when he sat down with me at the SHIEC Conference last month in Indianapolis. And that means that, under a Republican administration, it’s highly likely now that some of what Halamka and Tripathi have argued for in their NEJM op-ed probably will work out more in the direction that they foresee than the direction that perhaps the former National Coordinators envision it—though, to be honest, the former National Coordinators write rather vaguely about how interoperability might come about from a policy and regulatory standpoint, anyway.

What’s more, Dr. Rucker hinted to me very strongly that ONC’s focus will shift going forward. Indeed, though he refused to say so explicitly, he did not push back when I stated that it appeared that any final “Stage 3” of meaningful use for hospitals appears to be fading as a prospect, leaving the distinct possibility that ONC will begin now focusing away from what many clinicians and administrators have seen as more coercive requirements, and more towards an emphasis on stimulating the healthcare IT market, something that would greatly please Halamka and Tripathi and those who share their overall viewpoint.

Indeed, Dr. Rucker, in his interview with me in Indianapolis, put a strong focus on a market-driven push for value. “The challenge around value is that we’ve moved purchasing in healthcare from the free market and free-market equilibrium where consumers and producers agree on price, to a situation where we now have proxy consumers, which is the federal government and all the payers, who are trying to imagine what the consumer would pay for,” he told me. “And we’re trying to get the consumer back into the equation. The biggest way to do that, of course, is high-deductible health plans and health savings accounts; but one of the ways we’re trying to do this is through consumer access to data liquidity. And payers are consumers, too; and they need access to this data. So it really is broader than simply provider-to-provider data-sharing.”

In other words, it looks as though, inevitably, things are going to shift now, going forward, towards less comprehensive regulation and instead more towards the federal agencies that have oversight over federal healthcare IT policy, working to stimulate the marketplace.

The open question in all this is whether such a shift will get us to comprehensive interoperability faster or not; the jury honestly is very much out on that.

What is likely, though, is that HHS (the Department of Health and Human Services) and CMS (the Centers for Medicare and Medicaid Services), and ONC, might reduce the volume of process-oriented outcomes that Medicare-participating physicians will have to report to the federal government under the MIPS (Merit-based Incentive Payment System) system and the various APM- (advanced payment model) based programs under the governance of the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law’s requirements. Halamka and Tripathi definitely have a point about a need to shift outcomes reporting towards truly meaningful clinical outcomes, over time. It’s also important to keep in mind that, at the helm of ONC, Dr. Rucker is someone who spent decades in medical practice, and also worked as a health system administrator and as a vendor executive. So the chances that he will try to lift some of the burden on practicing physicians that Halamka and Tripathi cite in their op-ed, are relatively very good.

In the end, then, what some might find surprising is this: while the juxtaposition of the two NEJM op-eds was meant to create a conceptual and rhetorical contrast, the extent of commonality between the two is striking.

And, as Halamka and Tripathi note in their piece, “The HITECH era was an important catalyst for EHR adoption, and the industry benefited from government intervention. If the post-HITECH era can return control of the agenda to customers, developers, and multi-stakeholder collaborations, we should be able to recapture the hearts and minds of our clinicians.” Only time will tell, but there is a good hope that there will be enough of a meeting of minds among all the factions sitting around the federal healthcare IT policy table, that something close to an ideal of an overall policy thrust and emphasis, can be found, going forward. Our industry certainly deserves to get as close to that ideal as possible.




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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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