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Meaningful Use of EHRs Leads to Earlier Patient Discharge, Study Finds

November 27, 2018
by Rajiv Leventhal, Managing Editor
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In patient care facilities that meet the highest federal standards for implementing EHRs (electronic health records), greater savings were achieved by reducing the average length of patient stays, according to new research.

The study, from Case Western Reserve University, which examined four years of data, noted that at hospitals meeting the federal government’s measure of meaningful use of EHRs, patients are discharged nearly four hours earlier—approximately a 3 percent reduction of the average five-day hospital stay.

For sicker patients, the benefit was even greater: those with complex or multiple chronic conditions saw up to an additional 0.5 percent reduction in their hospital stays.

For the past several years, hospitals have been financially incentivized adopt and meaningfully use EHRs, while facing penalties for failing to do so, such as negative adjustments to Medicare and Medicaid reimbursement. The government dictates various measures and thresholds that providers must meet in order to get the bonuses and avoid the penalties.

What’s more, the researchers found that these shortened stays did not come with an increase in readmissions. “With prolonged patient stays costing hospitals an average of $600 a day, the use of electronic records could help contain growing costs, especially amid a trend of reduced reimbursements from insurance companies and entitlement programs,” the researchers noted.

And conversely, hospitals that did not fully engage in the meaningful use of EHRs showed no significant reductions in length of patient stays, according to the study, which was published in the Journal of Operations Management.

“Electronic health records, when meaningfully implemented help patients go home sooner, reducing their exposure to germs in the hospital and likelihood of having to come back," said Manoj Malhotra, dean of the Weatherhead School of Management at Case Western Reserve and co-author of the research.

Essentially every non-federal acute care hospital in the U.S. now has implemented certified EHR technology, and the study’s researchers believe that “a more proactive approach that meaningfully uses the technology beyond mere adoption may be needed to see more progress.”

The researchers categorized hospitals into one of three categories—partial adoption of EHRs, full adoption of EHRs and “meaningful assimilation” of EHRs.

“Whereas partial or full adoption showed no benefits for reducing patient stays, meeting the government’s highest standard of meaningful use reduced length of stay without any adverse impact on readmissions,” said Malhotra. “Results from this study indicate that meaningful assimilation of technology is likely to help free-up clinicians and other valuable resources. This approach is preferable to making additional investments in facilities or hiring additional employees as more people seek hospital services.”

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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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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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HHS Issues Comprehensive Draft Report with Eyes on Reducing Health IT Burden

November 28, 2018
by Rajiv Leventhal, Managing Editor
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Required by the Cures Act, the strategy lays out core issues and challenges related to health IT burden, while offering several recommendations

The Department of Health and Human Services (HHS) has issued a federal draft strategy designed to help reduce administrative and regulatory burden on clinicians caused by technology such as electronic health records (EHRs).

The draft strategy, which is 74 pages, was developed by the health IT arm of the federal government—the Office of the National Coordinator for Health Information Technology (ONC)—in partnership with the Centers for Medicare & Medicaid Services (CMS), and was required in the 21st Century Cures Act.

According to federal health IT officials, “The draft strategy reflects the input and feedback received by ONC and CMS from stakeholders, including clinicians, expressing concerns that EHR burden negatively affects the end user and ultimately the care delivery experience. This draft strategy includes recommendations that will allow physicians and other clinicians to provide effective care to their patients with a renewed sense of satisfaction for them and their patients.”

Based on the input received by ONC and CMS, the draft strategy outlines three overarching goals designed to reduce clinician burden:

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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...

1. Reduce the effort and time required to record health information in EHRs for clinicians;

2. Reduce the effort and time required to meet regulatory reporting requirements for clinicians, hospitals, and health care organizations; and

3. Improve the functionality and intuitiveness (ease of use) of EHRs.

Officials noted in the announcement today that healthcare stakeholders have indicated to ONC and CMS that when they use their EHRs, clinicians have to rely on checkboxes, templates, cut-and-paste functions, and other workarounds that hinder the intended benefits of EHRs. Clinicians have reported they are spending more time entering data into the EHR, leaving less time to interact with their patients. Required documentation guidelines have led to “note bloat,” making it harder to find relevant patient information and effectively coordinate a patient’s care.

According to ONC officials in a blog post accompanying the draft strategy today, “By releasing this draft strategy, we are taking one more step toward improving the interoperability and usability of health information by establishing a goal, strategy, and recommendations to reduce regulatory and administrative burdens relating to the use of EHRs.” But, they added, “We can’t do this alone. The Cures Act, and a thorough analysis of the drivers of burden, require that the government and industry work together to reduce the burden of using EHRs.”

Throughout the last few years, ONC and CMS have undoubtedly made burden reduction a top priority in their respective agencies. ONC even created a position in 2017— deputy assistant secretary for health technology reform—that would specifically focus on burden reduction, tapping John Fleming, M.D., a former Congressman and a practicing family physician to fill the role.

Meanwhile, CMS, in the last several months, has overhauled the  Medicare and  Medicaid Promoting  Interoperability  Program  (formerly known as the EHR Incentive Programs) and has proposed to overhaul the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category (formerly known as the Advancing Care Information performance category) to focus on interoperability, improve flexibility, and relieve burden.

In notable comments today from Donald Rucker, M.D., National Coordinator for Health IT, he said, “We look forward to advancing the premise of how to accurately model and support the clinical cognitive process in the EHR—a shift away from a strictly linear, logic-based model to a more sophisticated design that supports the complex pattern recognition inherent in the diagnostic and treatment process.”

Rucker added more details in his comments: “New healthcare-specific software design elements will help produce software tailored to the clinical workflow. We envision a time when clinicians will use the medical record not as an encounter-based document to support billing, but rather as a tool to fulfill its original intention: supporting the best possible care for the patient….Similarly, quality  reporting should be seamless, accessible  through  the metadata  in  the  EHR, and  available  through high-quality,  clinically mature application programming interfaces (APIs), which will reduce the need to separately submit data.”

The Cures Act, signed into law in December 2016, requires HHS to articulate a plan of action to reduce regulatory and administrative burden relating to the use of health IT and EHRs. Specifically, the Cures Act directs HHS to: establish a goal for burden reduction relating to the use of EHRs; develop a strategy for meeting that goal; and develop recommendations to meet the goal.

For this draft report, HHS reviewed stakeholder input and established four workgroups which included representatives from across HHS, including ONC, CMS, and other federal offices.  Each of these workgroups focused on a different aspect of EHR-related burden, specifically: clinical documentation; health IT usability and the user experience; EHR reporting; and public health reporting.

For each of these aspects, the report lays out what the core issues and challenges are, while then outlining an array of strategies and recommendations for improvement.

In a statement, HHS Secretary Alex Azar said, “Usable, interoperable health IT was one of the first elements of the vision I laid out earlier this year for transforming our health system into one that pays for value. With the significant growth in EHRs comes frustration caused, in many cases, by regulatory and administrative requirements stacked on top of one another. Addressing the challenge of health IT burden and making EHRs useful for patients and providers, as the solutions in this draft report aim to do, will help pave the way for value-based transformation.”

Added Seema Verma, CMS Administrator, “Over the past year, we hosted listening sessions, received written feedback, and heard from a wide range of clinical stakeholders about the current health IT systems and the requirements specifying documentation, reimbursement, and quality reporting that are burdensome and should be re-examined.” 

The public comment period on the draft strategy is open until January 28, 2019.


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