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EHRs’ Evolution: Are They Advancing Too Slowly?

August 24, 2016
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Doctors’ frustrations with EHRs are well-known and just, but history has taught us that technology will evolve

Last week, when I read a commentary from physicians in the Journal of the American Medical Association (JAMA) about their dissatisfaction with electronic health records (EHRs), I was particularly intrigued to see that the authors went to the next level in terms of specifically pinpointing their frustrations.

The piece, penned by Donna M. Zulman, M.D., Nigam H. Shah, Ph.D., and Abraham Verghese, M.D., all with affiliations to the Stanford University School of Medicine, titled “Evolutionary Pressures on the Electronic Health Record,” kicked off by mentioning that EHRs “have the potential to prevent medication errors and decrease duplicative tests, contributing to the safety and value of care.” But, the authors said, “The evolution of EHRs has not kept pace with technology widely used to track, synthesize, and visualize information in many other domains of modern life.”

More specifically, the authors said that the tools are not integrated in a way that supports tailored treatment decisions based on an individual’s unique characteristics. “Existing EHRs also have yet to seize one of the greatest opportunities of comprehensive record systems—learning from what happened to similar patients and summarizing that experience for the treating physician and the patient,” they wrote. They added that the most important shortcoming of the EHR might just be the absence of social and behavioral factors fundamental to a patient’s treatment response and health outcomes. “In this world of patient portals and electronic tablets, it should be possible to collect from individuals key information about their environment and unique stressors—at home or in the workplace—in the medical record. What is the story of the individual?” they wrote.

Of particular interest, the authors also stated that the amazing effects of computers and science are simply not seen with EHRs, leading to extra burden on physicians. “The dominant EHRs are designed for billing and not primarily for ease of use by those who provide care. In fact, a measure of successful EHR evolution may be that physicians spend much less time with the EHR than they do now,” they said. They continued, “Deimplementing the EHR could actively enhance care in many clinical scenarios. Simply listening to the history and carefully examining the patient who presents with a focused concern is an important means of avoiding diagnostic error.”

I’d like to touch on a few key points here: 1) These authors are hardly the first, nor will they be the last, to feel that EHRs as currently designed are essentially “billing machines” that don’t offer much in the department of improving patient care. 2) It has now become a must for provider organizations and the vendor community to move past the EHR adoption stage and into one where they will be able to optimize their investments. 3) A comparison of EHRs to the evolution of other technologies needs some perspective.

No, it’s not a surprise in the least to hear doctors complain about EHRs. Just yesterday, I read commentary from Niran Al-Agba, M.D., a pediatrician in Silverdale, Wash., who wrote about what her “ideal EHR” would look like. Al-Agba said she would like if the paper chart was simply replicated on the computer screen. “The first page would be a standard intake form providing the general health background, birth history, past medical and surgical histories, allergies, immunizations, medication list, and pertinent family history. The second page is the problem list and other necessary details depending on medical specialty. The third and fourth pages would be growth charts and then the immunization record follows. Those pages could be accessible by tabs on the left hand side of the screen to review or update when necessary,” she wrote.

Al-Agba argued that this level of simplicity—and with the note dictated into a SOAP (Subjective, Objective, Assessment, Plan) format—would accomplish the fundamental purpose of medical records, which is to chronicle all the diagnoses, treatments, and follow-ups for a variety of medical conditions. As such, providers would be happier given the ease of these “ideal” systems.

Undoubtedly, healthcare’s investment in EHRs and other technology has been a hefty one, to the tune of $30 billion as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 alone. Although data released earlier this year by the Office of the National Coordinator for Health IT (ONC) revealed that in 2015, 84 percent of the nation’s hospitals reported adoption of at least a basic EHR system—a nine-fold increase since 2008—physicians who continue to be hampered by these systems can’t help but wonder when they will see a return on the investment that can cost a single physician hundreds of thousands of dollars, according to at least one estimate.

Indeed, in the JAMA commentary, the authors noted how “the spectacular effects of computers in science and in the secular world are not reflected in the EHR,” and that “there is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians’ morale.” They added, “Current records miss opportunities to harness available data and predictive analytics to individualize treatment. Meanwhile, sophisticated advances in technology are going untapped.”

I certainly don’t doubt that the extra clicks and effort spent by doctors only increases their irritation with the technology. Nor do I deny that EHRs are probably not as sophisticated as they eventually will be. However, it’s important to have some perspective. As noted above, hospitals have seen a nine-fold increase in EHR adoption in the last eight years. The same study found that nearly all reported hospitals (96 percent) possessed certified EHR technology to meet meaningful use requirements in 2015. Eight years might seem like forever ago, but it’s really not. These sorts of major technology implementations and culture/workflow changes take a lot of time.

A second ONC data brief released around the same time found that interoperability among EHRs is largely a mixed bag, with shared information not being available to clinicians in their EHRs the biggest barrier. This data sharing phase is the next jump EHRs must make, and is also one of the main causes of aggravation for providers. But clearly, the federal government has made interoperability its next core goal for health IT. “Efforts that have focused on EHR adoption now are shifting to interoperability of health information, and the use of health information technology to support care delivery system reform,” that ONC data brief confirmed.

As such, it would be unfair to criticize all EHRs based on the current stage of evolution they’re in right now. But rather, what’s their trajectory? I compare it to before we had “smartphones.” Believe it or not, not too long ago, most of us just had plain old Nokia cell phones that really only had the ability to make and receive calls. Now, nearly seven in 10 U.S. adults own smartphones that possess the ability to essentially connect to anywhere in the world digitally. That smartphone ownership number has doubled in just the last four years, according to Pew Research.

Healthcare, of course, is a whole different animal with a wealth of data unmatched by other industries. But, that should make this point clearer: EHRs’ evolution must go through multiple stages, each of which might take years. So while I completely get providers’ qualms with EHRs, we need to also understand that technology won’t fail us; it rarely ever has. And before long, docs, your Nokias will become iPhones and Androids, too.

 

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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.

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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