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Why Leadership and Alignment are Crucial to Success in the New Healthcare

November 8, 2016
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At CHIME16, a key theme developed around C-suite leadership and partnership

It was fascinating to be at the CHIME16 CIO Fall Forum in Phoenix last week, where approximately 850 attendees, of which some 460 CIOs/College of Healthcare Information Management Executives (CHIME) members roamed the conference halls of the JW Marriott Phoenix Desert Ridge Resort, most with a common goal in mind: to share best practices and continue to learn about how to effectively set up their respective patient care organizations to succeed in healthcare’s changing paradigm.

While there were several broad topics at the CIO Fall Forum that were drilled down in thought-provoking breakout education tracks, the one core theme that stuck out to me was around healthcare C-suite leadership and the alignment of business and information technology goals. To this end, I wrote a story from the Forum about how Banner Health is doing exactly that, by creating a business plus IT partnership model that has driven increased organizational success.

Ryan Smith, senior vice president of IT and CIO of Banner Health, gave a few impressive anecdotes on how the health system, due to its streamlined operating model, was able to integrate data from acquired organizations’ business systems and electronic health records (EHRs) in essentially no time at all. During his presentation, Smith recalled Banner Health:

  • Integrating the business systems and EHR of Goldfield Medical Center in Junction Ariz., 30 days post-acquisition, without ever walking into the medical center prior to the merger
  • Integrating the business systems of Casa Grande Medical Center, located 20 miles south of Phoenix, in just one day post-acquisition
  • Integrating the business systems and EHR of Payson Medical Center in Payson, Ariz., both in just one day

As I reported last week, Smith credited these incredibly quick timeframes to Banner’s operating model. When discussing the model, Smith said: “It doesn't matter what EHR or network they put in, because at the end of the day, we recognize that our model requires consistency and allows us to be really fast when we think about M&A integration.” Indeed, he continued by noting that the model: assumes ALL acquisitions will be rapidly integrated; allows for less time spent on deciding whether or not to integrate; and provides a playbook for executing all phases of IT integration efforts.

This type of operational efficiency and organizational alignment at Banner Health, one of the largest integrated health systems in the U.S., can be tied to Banner’s dyad leadership model, which Smith explained partners a business “champion” with an IT “champion” for most things related to IT strategy and execution. “I coach my team to let that business or clinical champion run the meeting, and be the face whenever possible,” Smith said, comparing the relationship to Batman and Robin’s.

The dyad model continues to be a frequently used one in healthcare. Research from the Physician Executive Council in 2015 found that “dyads are a powerful solution to the basic problem of clinical leadership roles that are too big for any one individual—in terms of scope, competencies needed, constituencies represented, and more,” further noting examples of a “physician-administrative dyad pair at the Mayo Clinic standardized care across 22 EDs, and the hospitalist-nurse dyad leadership model that helps make the emerging model of the accountable care unit so effective).” The research also found that 88 percent of physician leaders surveyed in 2014 “agreed that dyads improve leadership performance and accountability.” The core behind the dyad leadership model is centered on: finding the right “champions”; properly defining roles; and demanding accountability, pundits say.

While leadership models can be debated in clinical and organizational circles forever, there is no hiding from the fact that the world is changing, and at CHIME16, there were plenty of conversations among CIOs about how to adapt to these changes, and thus “avoid minefields.” To this end, a panel discussion of two CIOs, a CIO recruiter and a consulting firm CEO discussed four such problem areas: privacy and security; disaster and downtime; troubled projects; and leadership change. In all four instances, the panelists agreed that partnering with the right people and being as transparent as possible are keys to avoid these minefields, or fight through them if they do occur.

One breakout discussion on security particularly piqued my interest. Keith Perry, senior vice president and CIO of Memphis, Tenn.-based St. Jude Children’s Research Hospital, said in the year he has been in that role, he has made effort to reach out to the CISO at the organization to “elevate” that person and that position. Perry said that a lot of people will focus on if the CISO reports to the CIO or elsewhere, but the real focus should be on getting that CISO to be a bigger part of formulating IT strategy. And it was at this time when the recruiter on the panel, Witt/Kieffer’s Chris Wierz, R.N., said that her firm gets flooded with CISO search requests. “So if you don’t have one, I would say hire one quickly. We are seeing these individual salaries go up by $50,000 each month,” Wierz said.

Another example of how leadership and partnership are so important came when Perry spoke about a storage outage at a company he was working with at the time that resulted in clinical systems being disabled, thus affecting patient care. “After we brought it back up in a few days, I talked to my CISO about being transparent about what happened during the downtime and why, and we brought in a company to do a root cause analysis, which we then took to our executive board. That was a good thing; we instilled trust in the process that we're engaged in the conversation and take these things seriously,” Perry said.

Indeed, these narratives do reveal one thing that is abundantly clear: with the way healthcare’s landscape is shifting, leadership and partnership across the healthcare C-suite is more important than ever before. Banner Health’s M&A activity serves as a prime example, and that health system is far from alone. Healthcare Informatics’ Editor-in-Chief Mark Hagland interviewed the Berkery Noyes Investment Bankers firm’s managing director Tom O’Connor this summer, who said, “Especially as you go to value-based, outcomes-based payment models, things are changing. Physicians get paid, or get penalized, for readmissions in 30 days. All this is driving independent physicians to work for hospitals or affiliate with hospitals. They can’t afford to be independent practitioners anymore, or take on risk.”

Another C-suite leadership trend is also noteworthy: healthcare professionals with both medical and business backgrounds are becoming much more desired in this new healthcare. As reported by Healthcare Informatics, Cejka Executive Search and the American Association for Physician Leadership’s 10th biennial Physician Leadership Compensation Survey found that as compared to physician leaders with no post-graduate degrees, a master's in business administration (MBA) earned respondents on average 13 percent more in salary and a certified physician executive (CPE) on average earned 4 percent more in salary.

Meanwhile, that same report found that the greatest increase in C-suite compensation since 2013 was 18 percent for physicians in the CIO and chief medical information officer (CMIO) roles, and the double-digit increase for CMIOs/CIOs is likely due to the roles' shift in focus—from electronic medical records implementation to ensuring the usability of data to support preventative care at the individual provider level and risk-based accountable care at the enterprise-level, according to the survey report authors. "Clearly, there is perceived value in having a physician leader drive these initiatives and facilities are willing to compensate accordingly," Paul Esselman, Cejka Executive Search’s senior executive vice president and managing director, said in a statement.

So what does all this signal? In a broad sense, healthcare’s changing paradigm means that all of these C-suite roles will undoubtedly become more strategic and complex. And drilling down, CEOs, CIOs, CMIOs, CFOs, chief medical officers (CMOs), chief operating officers (COOs) and chief innovation officers (yes, that’s a whole lot of Cs) will all have to work together and align goals to achieve the greater good—a patient-centered healthcare focused on value-based care that lowers costs by keeping patients out of the hospital. At CHIME16, it was refreshing to hear that many of the industry’s top leaders are recognizing how crucial these elements are to the future of healthcare.

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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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