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Media Report: Medical Errors Reported during Banner Health’s Switch to Cerner EHR

July 24, 2018
by Heather Landi
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After Phoenix-based Banner Health implemented a new Cerner electronic health record (EHR) at its Tucson, Arizona-based hospitals and clinics back in October, at a price tag of $45 million, there were “numerous” reports of medical errors, according to a state report obtained and reported on by the Arizona Daily Star.

In an article published Monday, Arizona Daily Star reporter Stephanie Innes reports that records of an Arizona Department of Health Services investigation into complaints about Banner’s EHR conversion indicate Banner’s Oct. 1 switch from Epic to Cerner “adversely affected patients and caused a high level of frustration among some staff members,” according to the article.

The Epic-to-Cerner switch followed Banner Health’s acquisition of the University of Arizona Health Network in 2015. Two years prior to its sale, the UA Health Network completed a $115-million Epic implementation.

According to the Star, citing a heavily redacted report, an October 19 complaint stated, “The biggest issue is patient safety and harm to patients,” and that “many of the staff are in tears and frustrated because of the lack of support and empathy to the consequences of patient care.”

Hospital leaders acknowledged delays in getting patients registered, delays in ordering and receiving lab results and delays in ordering and getting medications, records say, but said no patients were harmed, Innes reported.

“Hospital leadership denied there were any incidents that resulted in a negative outcome to patients, however, the hospital’s occurrence log for October 2017 showed numerous incidents of medical errors reported to be a result of the conversion,” state investigators wrote, as cited by Innes in the article.

The article reports, citing the investigation records, that the Arizona Department of Health Services did not fine or cite Banner. Banner took “sufficient corrective action” for issues raised in two substantiated allegations about the conversion, records show.

According to the article, state records indicate that the two substantiated allegations were connected to two October complaints about “the inability to reliably deliver medications, order tests and care for critically ill patients,” and “multiple computer/printer glitches” impacting patient care.

Banner Health officials declined an interview with the Star regarding the issue, but the health system said in separate emails that more than 100 improvements to the new Cerner electronic health records system have been implemented this year to streamline workflows and provide better access to information for physicians and staff.

“These changes include dramatic improvements in medications processing and pharmacy; improved administrative operations in our oncology department; and rapid and enhanced access to patient records for our clinical staff; to name a few,” one emailed statement to the Star reads.

The statement also read, “Along the way, we did experience challenges, some of which were significant. However, we are proud of the progress we have made, will continue to refine our systems and technology, and are more committed than ever to making sure the Banner experience is world class.”

“Banner’s conversion to Cerner in Tucson ultimately will allow for advanced clinical research with a large data set, benchmarking of clinical performance, improved quality, patient safety and a better patient experience, Banner officials say,” according to the Star article.

Banner Health senior executive leaders also are facing another significant IT issue—the federal government is investigating the health system’s IT security following the massive 2016 cyber attack that compromised the personal information of 3.7 million individuals.

An Ernst & Young 2017 year-end financial report on Banner Health notes that the health system has been the subject of an investigation by the Office of Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS).

“The OCR investigation is still active, and the OCR has indicated that the initial Banner responses with respect to its past security assessment activities are inadequate. Although Banner has supplemented its initial responses, Banner anticipates that it may receive negative findings with respect to its information technology security program, and that a fine may be assessed against Banner. At this point, it is not possible to estimate the range of potential fines by the OCR,” that report states.

That security incident was initiated on June 17, 2016, and was discovered by Banner in late June 2016. Banner computer systems that process credit card payments in food and beverage outlets at certain Banner locations were accessed by unauthorized persons. The attackers targeted payment card data, including cardholder name, card number, expiration date and internal verification code, as the data was being routed through affected payment processing systems.

Then, in July, Banner Health learned that the cyber attackers may have indeed gained unauthorized access to patient information, health plan member and beneficiary information, as well as information about physician and healthcare providers.

Banner Health also is facing a class action lawsuit filed in August 2016 on behalf of the 3.7 million individuals affected by the data breach. The plaintiffs, including a former ophthalmologist at Banner Thunderbird Hospital in Glendale, Arizona, alleged the health system failed “to take adequate precautions” like multi-factor authentication, firewalls and encryption.

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Study: EMR Interventions Help in Providing High-Value Medical Care

October 19, 2018
by Rajiv Leventhal
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By implementing electronic medical record (EMR)-based interventions, Boston Medical Center was able to reduce unnecessary diagnostic testing while increasing the use of postoperative order sets.

These actions signal two markers of providing high-value medical care, according to hospital officials. Indeed, the data from Boston Medical Center’s efforts demonstrates the impact of deploying multiple interventions simultaneously within the EMR as a way to deliver high-value care, they attest. This study was published in the Joint Commission Journal on Quality and Patient Safety.

The focus on providing high-value medical care was renewed in 2012 with the release of the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine Foundation that identifies common tests and procedures that may not have clear benefit for patients and should sometimes be avoided. Many institutions have responded to this campaign by developing EMR-based interventions that target individual recommendations.

Boston Medical Center (BMC) specifically focused on five areas in the Choosing Wisely recommendations:  the overutilization of chest x-rays, routine daily labs, red blood cell transfusions, and urinary catheters, and underutilization of pain and pneumonia prevention orders for patients after surgery. To do this, the researchers worked with the hospital’s IT team to incorporate new recommendations into the EMRs that would alert the provider to best practice information. The researchers examined data between July 2014 and December 2016 to look at how the interventions played out clinically.

At six months following BMC’s intervention, which was activated hospital-wide for specific patients using the Epic EMR, the proportion of patients receiving pre-admission chest x-rays showed a significant decrease of 3.1 percent, and the proportion of labs ordered at routine times also decreased 4 percent. Total lab utilization declined with a post-implementation decrease of 1,009 orders per month, the study revealed.

The researchers found no significant difference in the estimated red blood cell transfusion utilization rate or the number of non-ICU urinary catheter days, but the proportion of postoperative patients who received appropriate pain and pneumonia prevention orders showed an absolute increase of 20 percent, according to the researchers.

“The results from our interventions suggest that they alone show promise in improving high-value care, but using only an electronic medical record intervention may not be adequate to achieve optimal outcomes emphasized by Choosing Wisely,” said Nicholas Cordella, M.D., the study’s corresponding author, a fellow in quality improvement and patient safety at BMC, and an assistant professor at Boston University School of Medicine.

Cordella added, ““In order to move the needle on reducing unnecessary healthcare costs, we need to consider multi-pronged approaches in order to engage providers in ways that can truly make a difference in how we deliver exceptional, high-value care to every patient.” He suggested that future efforts aimed at increasing high-value care should consider other elements, such as clinician education, audits and feedback, and peer comparison.

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Industry Groups Urge ONC to Reorient Goals of EHR Reporting Program, Focus on Health IT Safety, Security

October 18, 2018
by Heather Landi, Associate Editor
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Many healthcare industry groups would like to see the Electronic Health Record (EHR) Reporting Program for health IT developers include a strong focus on patient safety-related usability, EHR training, transparency on EHR vendors’ cybersecurity practices as well as cost transparency.

This feedback came in response to a request for information (RFI) issued by the Office of the National Coordinator for Health IT (ONC) in late August seeking public input on reporting criteria under the EHR Reporting Program for health IT developers, as required by the 21st Century Cures Act. The public comment period ended Oct. 17.

ONC issued the RFI on criteria to measure the performance of certified electronic health record technology (CEHRT). The Cures Act requires that health IT developers report information on certified health IT as a condition of certification and maintenance of certification under the ONC Health IT Certification Program.

According to the Cures Act, the EHR Reporting Program should examine several different functions of EHRs and reporting criteria should address the following five categories: security; interoperability; usability and user-centered design; conformance to certification testing; and other categories, as appropriate to measure the performance of certified EHR technology.

In its comments to ONC, the Bethesda, Md.-based American Medical Informatics Association (AMIA) questioned what it views as the “constrained scope” of the EHR Reporting Program to “provide publicly available, comparative information on certified health IT,” to “inform acquisition upgrade, and customization decisions that best support end users’ needs.”

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Rather, AMIA urged ONC to develop the EHR Reporting Program to measure performance to improve CEHRT security, interoperability, and usability, and not be used simply to provide data for “acquisition decision makers.”

“Especially when viewed alongside the additional provisions in newly developed CEHRT Conditions of Certification, the EHR Reporting Program should be leveraged to bring transparency to how CEHRT performs in production environments with live patient data,” AMIA stated.

“ONC should develop an EHR Reporting Program that more closely approximates a post-implementation surveillance ecosystem, not a government-sponsored ‘consumer reports’,” AMIA wrote in its comments.

Such an ecosystem, AMIA stated, would “illuminate CEHRT performance used in production and would generate product performance data automatically, without users having to submit reporting criteria.”

As proof of concept, AMIA pointed to ONC’s existing nascent surveillance and oversight program for CEHRT that could be leveraged for the EHR Reporting Program. The group also referenced the Food and Drug Administration’s (FDA) Digital Health Software Precertification Program as another example of a federal program that looks to utilize real-world production data.

In addition, AMIA recommends ONC develop interoperability reporting criteria for the EHR Reporting Program by building on previous RFIs meant to “measure interoperability,” including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and ONC’s “Proposed Interoperability Standards Measurement Framework.”

And, the industry group also urged ONC to prioritize an additional measure that demonstrates a capability to provide patients with “a complete copy of their health information from an electronic record in a computable form.” “This focus would align with top-level HHS priorities to improve patient access to their data,” AMIA noted.

AMIA also recommends alignment between the EHR Reporting Program and other aspects of the Cures-mandated Conditions of Certification.

“The EHR Reporting Program is one more vital piece in improving both EHR performance and care quality,” AMIA president and CEO Douglas B. Fridsma, M.D., Ph.D., said in a statement. “We have a tremendous opportunity to leverage Cures provisions if we hone our focus on EHR performance in the real world.”

In its comments, the College of Healthcare Information Management Executives (CHIME) advises ONC against establishing any complex rating methodologies for scoring vendors. ONC should also consider establishing benchmarks by which to monitor interoperability progress among vendors, CHIME wrote. The organization noted that patients need better education on the risks of using application programming interfaces (APIs), and ONC should partner with their federal partners and stakeholders on this issue, CHIME said.

Many organizations, including CHIME, would like more information about vendors' ongoing support practices, such as the estimated costs of maintenance and software. The Medical Group Management Association (MGMA) recommended making software pricing structures for upfront and ongoing software, training and maintenance costs part of the Reporting Program, as well as all interoperability “connection” fees. MGMA also urged ONC to consider incorporating into the Reporting Program testing criteria that focused on the effectiveness of the EHR’s integration with practice management system software, and costs associated with it.

The American Health Information Management Association (AHIMA) recommended that comparative information made publicly available under the EHR Reporting Program should also contain reporting criteria that reflects the entire lifecycle of the certified health IT product, including acquisition, implementation, ongoing maintenance, upgrades, additional product and/or application integration, and replacement.

Focus on Patient Safety-Related Usability and EHR Training

In its comments, AMIA also urged ONC to view health IT safety as a measurable byproduct of usable CEHRT deployed in live environments. “To understand CEHRT usability performance in situ, ONC should supplement user-reported measures with measure concepts that reflect the safety of health IT,” AMIA wrote.

MGMA recommended that the Reporting Program report on the ability of the software to identify and address patient safety issues. “Poor usability and inefficient clinician workflow can not only fail to prevent adverse events but can actually contribute to them,” the organization wrote.

In comments it submitted to ONC, Pew Charitable Trusts noted that the establishment of the EHR Reporting Program “has the potential to give health care providers, EHR developers, and other organizations better data to address barriers in the effective, efficient, and safe use of health information technology, and improve systems accordingly.”

“In particular, this program could unearth key details on how clinicians utilize EHRs to meet ONC’s goal of reducing clinician burden while improving patient safety. ONC should ensure that the reporting criteria focused on usability—which refers to the design of systems and how they are used by clinicians—also incorporate safety-related provisions,” Pew wrote in its letter.

Pew recommended reporting criteria focus primarily on testing EHR usability to promote patient safety. To this end, Pew identified four principles to guide usability-related reporting criteria—the adoption of a life-cycle approach to developing usability-related criteria; incorporating quantitative, measurable data; limiting burden on end-users; and ensuring transparent methods that prevent gamesmanship.

Pew also provided ideas for existing sources of information that could be adapted into or utilized as safety-related usability reporting criteria, such as the Leapfrog CPOE tool, safety surveillance data from ONC, the ONC SAFER Guides or a 2016 health IT safety measure report from NQF.

“As ONC implements this program, the agency should ensure that the usability aspects of the program focus on the facets of EHR usability that can contribute to unintended patient harm. To achieve that goal, ONC should consider the aforementioned principles in identifying reporting criteria, and data sources that could become part of the program,” Pew wrote in its comments.

Orem, Utah-based KLAS Research and the Arch Collaborative recommended the EHR Reporting Program include criteria focused on EHR training, as better clinician training is critical to EHR usability and clinician satisfaction, the two groups said. The Arch Collaborative is a KLAS-affiliated initiative with more than 130 provider members.

The KLAS-Arch comment cited research findings based on responses by more than 50,000 physicians from more than 100 provider organizations around the globe that suggests EHR satisfaction and usability are directly related to the extent and quality of training users have received. The research indicates that organizations that focus on training to support clinician workflows have higher EHR satisfaction than those that don’t. What’s more, the higher the levels of personalization tool use by the clinicians, the higher the EHR satisfaction score, according to KLAS.

“EHRs are not simple enough to be operated efficiently without ample instruction. It is essential that new providers spend enough time learning how to use the EHR, and it is requisite that providers have the option to participate in ongoing training each year,” Taylor Davis, vice president of innovation at KLAS Research, wrote in the letter. “When an EHR training program is well designed, there will be a demand to attend. A trend that has been noted is that success begets success; when providers share how EHR training has improved their efficiency, their peers become more likely to participate. The key is that the providers must have the option to choose what works for them.”

Need for Greater Focus on Security Posture

The Healthcare and Public Health Sector Coordinating Council's cybersecurity working group highlighted, in its comments on the RFI, the need for more transparency on EHR vendors' cybersecurity posture as part of the criteria of the EHR Reporting Program.

“The challenges to our sector are abundant and we believe these attacks pose direct threats to patient safety,” the group wrote in its comments. The group urged ONC to factor into the EHR Reporting Program the growing incidences of cybersecurity attacks on the sector and the need to work collaboratively to address the threats.

The group outlined a number of items that would better inform providers of a vendors’ security practices, such as access to an auditor’s statement regarding the security posture of the vendor and its products, upon provider request, as well as a software security analysis, whether two-factor authentication is in use, information on role-based access controls and how roles are configured, and, with each release and update, the number of patches provided to address security-related issues.

The group also recommended ONC consider developing a more standard way for vendors to report vulnerabilities with health IT upgrades and releases.

 


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UnitedHealth Group Plans to Unveil Health Record for Members, Providers in 2019

October 17, 2018
by Rajiv Leventhal, Managing Editor
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Health insurer UnitedHealth Group will be unveiling a “fully integrated and fully portable individual health record,” CEO David Wichmann said on the on the company’s third-quarter earnings call yesterday.

Speaking to the insurer’s broader digital health strategy, Wichmann stated on the earnings call that the company’s consumer digital health platform, Rally—which is a website and mobile app—is now serving over 20 million registered users and will leveraged to help develop the health record.

“Rally is synthesizing information and engaging people to better manage their health, helping consumers save money by selecting the highest quality care providers, understanding their out-of-pocket costs up front, and in some markets even scheduling appointments for care. We will soon be releasing at scale a first-of-kind, fully integrated and fully portable individual health record that delivers personalized next-best health actions to people and their caregivers,” Wichmann said on the call.

While many more details are not yet known about the health record, Wichmann did say that by the end of 2019, the insurance giant has the goal of developing individual health records for the 50 million fully benefited members that it serves, as well as for their care providers.

He noted, “We would use the Rally chassis…to provide individuals in a way in which they can comprehend a tool, if you will, not only outlining their individual health record, but also giving them next-best action detail. That's what I mean by when I say it's deeply personalized. It's organized around them, not based upon generic criteria. It also assesses to what extent that they've been, and how they've been served by the health system broadly, and whether or not there's been any gaps in care that have been left behind.”

Giving a little bit more information about the vision UnitedHealth Group has in regard to the health record, Wichmann said, “You might imagine what that could ultimately lead to in terms of a continuing to develop a transaction flow between the physician and us and the consumer and us, as we us being the custodian to try to drive better health outcomes for people, but also ensure that the highest level of quality is adhered to.”

As of now, the platform appears to be more geared toward consumers than providers. Steven Halper, an analyst for financial services company Cantor Fitzgerald, noted in an update that “The Rally EHR should be able to tap into different EHRs that use APIs [application programming interfaces] and other interoperability standards, which are being more-widely adopted. Rally EHR should be viewed as a consumer engagement tool and not as a threat to legacy provider EHR products.”

UnitedHealth Group already has its Optum business line, a health innovation company that provides health services in an array of different ways, including through its growing data analytics capabilities.

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