With MDs at the Helm, Might Some of Health IT’s Burdens Be Behind Us? | Rajiv Leventhal | Healthcare Blogs Skip to content Skip to navigation

With MDs at the Helm, Might Some of Health IT’s Burdens Be Behind Us?

July 13, 2017
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Practicing physicians are hopeful that MDs in key governmental leadership positions could help reduce the frustrations that EHRs have put on them

For those of you who are sports fans and who watch a lot of games, you probably can appreciate how important it is to have good broadcasters working the game on TV. Most of the time, there are two broadcasters in the booth— the “play-by-play” person who usually has announcing expertise; and the “color” commentator who is often an ex-athlete. Having a former athlete on the broadcast makes for a better viewing since that person has been in the trenches before, and can explain many of the detailed nuances of the game that would simply be too tough for someone without that game experience. What’s more, current athletes are often more comfortable talking to and being interviewed by ex-players. That camaraderie in the professional athlete world creates somewhat of a fraternity among players.

I bring this up because it reminds me of what we’re seeing in federal health IT policy right now. In recent months, and perhaps even longer, one of the main narratives in this industry has been how doctors around the country have become increasingly frustrated with electronic health record (EHR) usability. This frustration has gained significant momentum of late; just this week in a press briefing, ONC (Office of the National Coordinator for Health IT) leadership once again affirmed that reducing the burden that health IT puts on doctors will be a core emphasis for the agency going forward. Said Donald Rucker, M.D., National Coordinator for Health IT, in the call with media, “[EHRs] are right now about documentation and billing, but every other industry uses its enterprise computer software to do automation to become more efficient. We are the only business to use computers to become less efficient.”

Headlining that briefing was Rucker and John Fleming, M.D., deputy assistant secretary for health technology reform. The two of them, along with Health and Human Services (HHS) Secretary Tom Price, M.D., together bring a wealth of physician practice experience that the new administration hopes will have a profound impact on how health IT usability could be improved.

Notably, a position inside the government was created for Fleming, a former Navy physician who then opened his own private independent practice in the 1980s, signaling the importance the feds are placing on helping out small practices with technology. And Price, the HHS Secretary appointed by President Trump, is actually the first in his position with a medical degree since Dr. Louis Sullivan who served under the elder President Bush some 25 years ago.

Indeed, there seems to be a sense of camaraderie here, too, as current practicing physicians hope that these trio of MD leaders in the government, along with others as well, will lead to easier days ahead in regard to technology use.

When it was confirmed that Rucker and Fleming would be hired to team up with Price, Farzad Mostashari, M.D., former ONC chief in the Obama administration, told me, “The administration seems to taking [health IT] seriously and seems to be appointing someone serious with longstanding experience who is qualified to lead this next phase of the work of the office. And that’s a relief.” Added Arien Malec, vice president of data platform and acquisition tools for RelayHealth (an Alpharetta, Ga.-based McKesson business unit), and formerly an ONC staffer, “In aggregate [with Fleming and Rucker], what you have in this administration is a solid health IT leadership team that covers the basis of understanding the needs of providers, the perspective of vendors, and also the needs of policymakers, both at the Centers for Medicare and Medicaid Services [CMS] and on the Hill. And in general, that’s a strong set of assets to bring to bear on this challenge.”

Have We Reached a Tipping Point?

There have been a few turning points that one can look back on and see how this narrative of “reducing the burden” has evolved into what it is today (To be realistic, the broader theme of burdens on practicing physicians has been around for decades going to back to at least the introduction of Medicare and Medicaid in the 1960s).

For one, it was actually the CMS Administrator in the previous administration—Andy Slavitt (not an MD himself, but absolutely an advocate for helping physicians) who said during a conference early on in 2016 that due to the complexities involved with federal mandates such as the meaningful use program, “We have to get the hearts and minds of physicians back. I think we’ve lost them.”

In the year following those comments until his time as CMS head was up, Slavitt doubled and tripled down on this sentiment, making trip after trip to physician practices all over the U.S. in an attempt to see first-hand how technology was burdening them, and how CMS regulations could be better structured for them. At HIMSS 17, Slavitt again made headlines, saying that vendors should stop spending $2 million on exhibitor booths at HIMSS until they have "thrilled their customers."

Another turning point was a study published last fall in the Annals of Internal Medicine that got a massive amount of attention in health IT circles. Researchers  for this study concluded that for every hour physicians provide direct clinical face time to patients, nearly two additional hours is spent on EHR and desk work within the clinic day, And, outside office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work. Federal health IT administrators have referenced this study numerous times since it was released, using it as tangible proof that technology must work better for physicians going forward.

What Can Be Done?

Of course, the million dollar question (or $30 billion question, if you count what the government has invested in health IT via HITECH) has become what can the various stakeholders involved do to solve this compounding issue? In the briefing this week, Rucker said that the agency is looking at documentation requirements for physicians as well as the whole quality framework around value-based purchasing, and other regulations related to how systems are architected. “For a lot of practices, this has become a challenge in that we have to think about what the win is for them. The expense that [comes with] complying with the quality measures [compared with] the innate value [gained] needs to be analyzed at some point,” he said.

This also brings up another core point, which is will MACRA/MIPS reporting requirements further burden clinicians as meaningful use directives have in the past? Doctors seem to be growing quite tired of “checking boxes” and being data entry clerks just so that they can meet these federal reporting mandates. For the most part, they appear to believe in the shifting landscape that will reimburse them for quality outcomes, but they don’t feel like it’s necessary for the government to check up on them every step of the way.

And therein lies the hope that has been presented in front of the industry—the trio of Price, Rucker and Fleming, MDs who will try to help lead physicians out of this messy situation. One thing we are sure of is that there will be no turning back to paper medical records, so it’s up to these federal leaders, the vendor community, and yes, doctors, too, to work together for an improved solution. But I do have hope that better days are ahead of us—and just like seeing ex-athletes helping us answer sports’ toughest questions, I think MDs at the helm of key healthcare agencies will turn out to be a positive for the health IT industry.

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

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Research: Physician Burnout is a Public Health Crisis; Improving EHR Usability is Critical

January 18, 2019
by Heather Landi, Associate Editor
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Physician burnout is a public health crisis and addressing the problem requires improving electronic health record (EHR) standards with a strong focus on usability and open application programming interfaces (APIs), according to a new report from leading healthcare researchers.

The report is a “call to action,” the researchers wrote, “to begin to turn the tide before the consequences grow still more severe.” The researchers also recommend “systemic and institutional reforms” that are critical to mitigating the prevalence of burnout.

The result of collaboration between researchers with the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T. H. Chan School of Public Health, and the Harvard Global Health Institute, the report's aim is to inform and enable physicians and health care leaders to assess the magnitude of the challenge presented by physician burnout in their work and organizations, and to take appropriate measures to address the challenge, the researchers say.

The report also offers recommended actions for healthcare leaders to take, which the researchers acknowledge are not exhaustive, but “represent short-, medium-, and long-term interventions with the potential for significant impact as standalone interventions.”

The authors of the report include Ashish K. Jha, M.D., the K.T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health, and director of the Harvard Global Health Institute; Andrew Iliff, lead writer and program manager, Harvard Global Health Institute; Alain Chaoui, M.D., president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration, Massachusetts Health and Hospital Association; Maryanne Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael Miller, director, practice solutions and medical economics, Massachusetts Medical Society.

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession, according to the report.

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000-$1,000.000. 

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” Dr. Jha, a VA physician and Harvard faculty member, said in a statement in a press release accompanying the report. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

The beginning of the physician burnout crisis can be traced back to several events, according to the researchers, including the “meaningful use” of electronic health records, “which transformed the practice of many physicians, and was mandated as part of the 2009 American Reinvestment and Recovery Act.” Going back further, the 1999 publication of the Institute of Medicine’s “To Err is Human” highlighted the prevalence of medical errors, brought new attention to quality improvement and the value of physician reporting and accountability, the report states.

The researchers note that the primary impact of burnout is on physicians’ mental health, “but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public,” the researchers wrote.

The researchers note, “If we do not immediately take effective steps to reduce burnout, not only will physicians’ work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe.”

And, while individual physicians can take steps to better cope with work stress and hold at bay the symptoms of burnout, “meaningful steps to address the crisis and its root causes must be taken at a systemic and institutional level,” the researchers wrote.

According to the researchers, the primary drivers of physician burnout are structural features of current medical practice. “Only structural solutions — those that better align the work of physicians with their mission — will have significant and durable impact,” the researchers wrote in the report.

To that end, the researchers’ immediate recommendation is for healthcare institutions to improve access to and expand health services for physicians, including mental health services.

In the medium term, technology can play a large role. Addressing physician burnout will require “significant” changes to the usability of EHRs, the researchers wrote, including reform of certification standards by the federal government; improved interoperability; the use of application programming interfaces (APIs) by vendors; dramatically increased physician engagement in the design, implementation and customization of EHRs; and an ongoing commitment to reducing the burden of documentation and measurement placed on physicians by payers and health care organizations.

New EHR standards from the Office of the National Coordinator for Health IT (ONC) that address the usability and workflow concerns of physicians are long overdue, the researchers state. One promising solution would be to permit software developers to develop a range of apps that can operate with most, if not all, certified EHR systems, according to the report. The 21st Century Cures Act of 2016 mandates the use of open APIs, which standardize programming interactions, allowing third parties to develop apps that can work with any EHR with “no special effort.” There already have been efforts on this front, such as Epic’s “App Orchard,” the researchers note, but more work remains to be done.

To expedite this critical process of improvement, the report recommends physicians, practices, and larger health care delivery organizations, when seeking to purchase or renew contracts for health IT, adopt common RFP language specifying and requiring inclusion of a uniform health care API.

The researchers also say that artificial intelligence (AI) can play a promising role as AI technologies can support clinical documentation and quality measurement activities.

Long term, healthcare institutions need to appoint executive-level chief wellness officers who will be tasked with studying and assessing physician burnout. Chief wellness officers also can consult physicians to design, implement and continually improve interventions to reduce burnout, the researchers wrote.

“The fundamental challenge issued in this report is to health care institutions of all sizes to take action on physician burnout. The three recommendations advanced here should all be implemented as a matter of urgency and will yield benefits in the short, medium, and long term,” Jha and the research team wrote.

 

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GAO Report: Patient Matching Efforts Can Be Significantly Improved

January 17, 2019
by Rajiv Leventhal, Managing Editor
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The report did conclude that no single effort would solve the challenge of patient record matching

There is a lot that can be done—such as implementing common standards for recording demographic data—to improve patient matching, according to a new Government Accountability Office (GAO) report that closely examined the issue.

The 21st Century Cures Act included a provision for GAO to study patient record matching, and in this report, GAO describes (1) stakeholders' patient record matching approaches and related challenges; and (2) efforts to improve patient record matching identified by stakeholders.

The 37 stakeholders that GAO interviewed, including representatives from physician practices and hospitals, described their approaches for matching patients' records—comparing patient information in different health records to determine if the records refer to the same patient.

The respondents explained that when exchanging health information with other providers, they match patients' medical records using demographic information, such as the patient's name, date of birth, or sex. This record matching can be done manually or automatically. For example, several provider representatives said that they rely on software that automatically matches records based on the records' demographic information when receiving medical records electronically.

Stakeholders further said that software can also identify potential matches, which staff then manually review to determine whether the records correspond to the same patient. They said that inaccurate, incomplete, or inconsistently formatted demographic information in patients' records can pose challenges to accurate matching. For example, records don't always contain correct information (e.g., a patient may provide a nickname rather than a legal name) and that health IT systems and providers use different formats for key information such as names that contain hyphens.

Those who GAO interviewed identified recent or ongoing efforts to improve the data and methods used in patient record matching, such as the following:

  • ·         Several stakeholders told GAO they worked to improve the consistency with which they format demographic data in their electronic health records (EHR). In 2017, 23 providers in Texas implemented standards for how staff record patients' names, addresses, and other data. Representatives from three hospitals said this increased their ability to match patients' medical records automatically. For example, one hospital's representatives said they had seen a significant decrease in the need to manually review records that do not match automatically.
  • ·         Stakeholders also described efforts to assess and improve the effectiveness of methods used to match patient records. For example, in 2017 the Office of the National Coordinator for Health Information Technology (ONC) hosted a competition for participants to create an algorithm that most accurately matched patient records. ONC selected six winning submissions and plans to report on their analysis of the competition's data.

Those who were interviewed said more could be done to improve patient record matching, and identified several efforts that could improve matching. For example, some said that implementing common standards for recording demographic data; sharing best practices and other resources; and developing a public-private collaboration effort could each improve matching.

Stakeholders' views varied on the roles ONC and others should play in these efforts and the extent to which the efforts would improve matching. For example, some said that ONC could require demographic data standards as part of its responsibility for certifying EHR systems, while other stakeholders said that ONC could facilitate the voluntary adoption of such standards. Multiple stakeholders emphasized that no single effort would solve the challenge of patient record matching.

To this end, a recent report from the Pew Charitable Trusts outlined several key themes related to patient matching, while also suggesting recommendations to improve matching and the infrastructure needed for more robust progress in the medium and long term.

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Montana Senator to VA CIO: “EHR Modernization Cannot Fail”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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Senate VA (Department of Veterans Affairs) Committee Ranking Member Jon Tester has urged new VA CIO James Gfrerer to avoid past failures as he helps to move forward the department’s EHR (electronic health record) modernization project.

Gfrerer, an ex-marine and former executive director at Ernst & Young, was recently confirmed by the Senate to serve as assistant secretary of information and technology and CIO (chief information officer) at the Department of Veterans Affairs.

One of Gfrerer’s top tasks will be helping to update hospitals’ infrastructures as the VA continues to work on replacing the department’s 40-year-old legacy EHR system, called VistA, by adopting the same platform as the U.S. Department of Defense (DoD), a Cerner EHR system. That contract was finally signed last May and the implementation project is scheduled to span over 10 years.

In a letter to Gfrerer, Tester, a Montana senator, noted that while many of the responsibilities for the implementation of VA’s new EHR fall to the recently created Office of Electronic Health Record Management, the CIO’s role “is critical to ensure that we do not repeat the mistakes of the past.”

The office that Gfrerer now leads, VA’s Office of Information and Technology, will still be in charge of managing infrastructure needs for both the patient care facilities that have received the EHR upgrades and those that have not, Tester stated. “This task will require significant resources and robust oversight as VA manages a decade-long rollout,” he said.

Tester further wrote, “EHR modernization cannot be allowed to fail, and your leadership is essential if VA is to ultimately achieve a truly interoperable health record for veterans.”

In regard to “past failures,” it’s possible that Tester is referring to media reports that have outlined some of the significant issues that the DoD has had with its own Cerner rollouts. In reports throughout 2018, the initial feedback on the four military site EHR rollouts has been less than ideal. A Politico report first detailed the first stage of implementations noted that it “has been riddled with problems so severe they could have led to patient deaths.” Indeed, some clinicians at one of four pilot centers, Naval Station Bremerton in Washington, quit because they were terrified they might hurt patients, or even kill them, the report attested.

Providing an update on Cerner’s progress with the DoD EHR implementations, a company executive recently noted that he is seeing “measurable progress” at the DoD’s initial operational capability (IOC) sites.

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