For Documentation Reform, Innovative Processes Breed Better Outcomes | Rajiv Leventhal | Healthcare Blogs Skip to content Skip to navigation

For Documentation Reform, Innovative Processes Breed Better Outcomes

September 28, 2017
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As you may have heard, physicians are feeling incredibly burnt out. Changing the way clinical records are generated could alleviate some of the stress

"If we weren’t already doing it this way, is this how we would start?”

Last week, I was at a healthcare conference in Boston where Paul DePodesta, current chief strategy officer for the NFL’s Cleveland Browns, delivered the event’s closing keynote. DePodesta, who is most well-known for his appearance in the book and movie Moneyball, which was based on the MLB’s Oakland Athletics’ analytical, evidence-based, sabermetric approach to assembling a competitive baseball team, was called an “analytics expert” by the local Cleveland media when the Browns hired him.

But DePodesta was not at the conference to talk about healthcare or health IT; rather to discuss how to sharpen an organization’s competitive edge through a variety of innovative approaches centered on big data and applicable analytics. Indeed, the “moneyball” methodology has become a core strategy for business leaders looking for new approaches for revamping stagnant systems.

The above quote from DePodesta makes me think about clinical documentation, and how new approaches are helping to transform how physician notes are generated. As I wrote about in the Healthcare Informatics September/October cover story, in the shift to value-based healthcare, increased demands have been placed on physicians to be far more accurate in the clinical record. As you may have heard already, MDs feel more stressed out than perhaps ever before, with documentation burdens serving as a leading driver for that tension.

As Rasu Shrestha, M.D., chief innovation officer for UPMC (University of Pittsburgh Medical Center), said in the feature story, physicians’ caseload indexes continue to increase, and oftentimes the severity of these patients’ conditions continues to increase. “And the options we have around how we treat these patients continue to go up, too. What all this means is that there is a lot of pressure amongst clinicians to up their game, not just doing the clerical work that’s required around the care process, but also meeting the demands of their large caseloads. And at the same time you cannot falter; if one thing goes wrong, there’s a human life at the other end,” Shrestha said.

Indeed, with healthcare comes an enormous amount of responsibility to be right—and not just most of the time, but every time. So what can be done to alleviate these pressures so that doctors can go back to focusing on what they do best, which is taking care of patients?

As I noted in the story, UPMC is just one leading healthcare organization that has taken to natural language processing (NLP) to aid in clinical documentation. NLP—a technology that allows providers to gather and analyze unstructured data, such as free-text notes—has great potential to increase efficiency without detriment in document quality, as some researchers have stated, since it can make sense of the unstructured free text that is often “trapped” in clinical notes.

For instance, in the story, Elizabeth Marshall, M.D., director of clinical analytics at Linguamatics, a U.K.-based NLP-based text mining software provider, simplified how the technology can be so helpful with documentation. Marshall noted that structured data does a very good job of telling the “what” of a patient’s story, as in what has happened to them (what the patient’s conditions, procedures, and labs are, for instance), but this structured data is limited when it comes to telling the “why,” as the why is predominantly hidden in unstructured form.

She added that if the patient has documented uncontrolled diabetes, this can be well represented in structured form. “But, why is it uncontrolled? Maybe the patient simply doesn’t want to take the medications, or perhaps he or she is unable to get to the pharmacy, or maybe he or she has a form of cognitive impairment and forgets to take his or her meds. What we need to know to answer that question is, what’s the underlying issue? Social determinants of health play a major role in this and they are often trapped in clinical notes. Knowing the reason why is the first step to addressing the problem, and unstructured data may be the primary place to find those answers,” Marshall said.

Meanwhile, back at UPMC, leaders at the 20-plus-hospital health system took to creating its own NLP product with the help of a then-Silicon Valley startup. The product, called HCC Scout, specifically utilizes NLP and big data to identify documentation that is in the clinical record to support the coding of specific conditions relevant to the risk adjustment model. As Shrestha told me, HCC (hierarchical condition category) coding—used by insurance companies to determine patients' future medical needs—is incredibly important when it comes to reimbursement and ICD-10 codes. UPMC implemented the HCC Scout product, with its engine that looks for documentation that is relevant for the risk adjustment coding, at one of its hospitals, and in the first year alone, the hospital saw upwards of $29 million in annual revenue.

Circling back to DePodesta’s presentation, and his quote about how many businesses approach processes, the way in which provider organizations think about clinical documentation is certainly changing. For years and years, “note bloat”—a problem that is often caused by physicians copying and pasting data from a patient's older record rather than manually generating new information—has plagued clinicians and led to inconstancies when notes get passed along the care continuum. And a part of that issue is that documentation has always been done a certain way, with not enough of a focus on how it can be improved.

As Editor-in-Chief Mark Hagland reported in last year’s Top Ten Tech Trends, in the world of value-based care, documentation reform is now upon us. For his piece, Hagland interviewed Vivek Reddy, M.D., then-CMIO at UPMC (now at Intermountain Healthcare), who spoke about how documentation has become a way to help patients co-manage their diseases—“so that you understand your treatments and the rationale between them.” Reddy said, “This is going to drive a different level of health literacy expectations. And that automatically changes not only accuracy, but style, and completeness aspects of this, for physicians. I think it’s actually a pretty exciting time. In the old days, the doctor would take a note on paper and keep it in a lock box until the next time they saw the patient; but all this is changing that dynamic.”

Indeed, it is all changing, and technologies such as NLP are a big reason why. At some point in their push for better quality, clinical and IT leaders realized that if their old processes around documentation weren’t etched in their workflows for the past several years, they would never have started that way. And now, with value-based care and a great desire to be accurate in the patient’s record serving as leading drivers, documentation reform is clearly present. Sometimes, change can be that simple.

Have any thoughts or questions? Feel free to tweet at @RajivLeventhal or comment in the section below.

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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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