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Report: Clinical, IT Leaders Need to Increase Collaboration on IT Investments

May 19, 2017
by Heather Landi
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The report also suggests IT leaders should engage more with frontline care teams to understand how clinical IT impacts workflow
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The majority of clinical leaders (54 percent) and IT leaders (51 percent) report that they work together on defining system requirements for clinical IT investments, according to a new report.

However, the report also found that clinical leaders are more likely to see the value in going beyond leader collaboration and directly consulting with frontline team members to understand actual workflow. One in five clinical leaders cited taking this approach, according to the survey, with fewer IT leaders taking this approach (only 14 percent). This suggests, the report authors wrote, a potential opportunity for IT team members to shadow clinical staff to truly understand how the clinical IT systems they select will be used in the real-world environment.

In organizations that do not take that collaborative approach, the IT leaders are more likely to take the lead on requirements definition to ensure security and to ensure that the clinical IT systems fit with legacy systems. Twenty-seven percent of IT respondents and 20 percent of clinical respondents cited IT leaders as taking the lead on this.

HIMSS Analytics and health IT company Vocera surveyed approximately 125 clinical and IT leaders from U.S. health systems, hospitals and outpatient facilities during the 2017 HIMSS Conference and Exhibition back in February in Orlando, with the goal of exploring how clinical and IT leaders collaborate to identify and deploy future healthcare technologies.

In the report’s research findings, it is noted that clinical team members at hospitals and health systems increasingly interact with information technologies designed to facilitate, streamline, and document care. For these clinical IT systems to deliver on their promises, they must be designed and deployed in a way that supports rather than hinders clinical workflows and communication. To achieve optimal outcomes, these systems require a new depth and degree of collaboration between clinical leaders who understand medical and nursing care, and IT leaders who understand technical integration and security requirements.

The survey found that clinical and IT leaders agree that the most important value of clinical IT systems is to help safeguard against clinical errors and ensure patient safety. However, after that, opinions across the two groups diverge. “Twice as many IT leaders cited access to clinical data for clinical decision support as a critical function of clinical IT solutions, and mentioned the need to for these platforms to save clinicians time and effort by streamlining clinical workflow,” the report authors wrote. The report authors also concluded that clinical leaders are much more aware of the increasing workload and pressures that are burdening frontline doctors, nurses, and other care team members. “For these leaders, access to data and streamlined workflows hold equal sway,” the authors wrote.

Regarding how organizations assess the need for clinical IT solutions, the report found that the majority of clinical leaders (54 percent) and IT leaders (49 percent) reported that they work together with frontline team members to identify gaps in the care experience that can be filled by clinical IT solutions, according to a new report.

For those organizations that don’t take this collaborative approach, clinical leaders are more often the ones taking the lead, according to 22 percent of respondents, the survey found.

The report also found that clinical leaders see themselves playing a much stronger role in identifying clinical IT solution needs. “They are significantly less likely than their IT peers to see the role that IT leaders play in identifying new system capabilities. Clinical leaders are also far more likely to believe that regulatory requirements shape a significant portion of clinical IT solution decisions,” the report authors wrote. To this point, only 4 percent of clinical leaders agreed with the statement, “IT leaders recognize gaps in current system capabilities and propose solutions.”

Overall, of all the respondents, 22 percent see clinicians identifying challenges and requesting solutions while only 14 percent see IT leaders as recognizing gaps and proposing solutions.

According to respondents, collaboration between clinical and IT leaders continues after requirements definition and into the selection and implementation process. Sixty-six percent of IT leaders and 63 percent of clinical leaders said that they work together in the selection and implementation process. However, only 31 percent of IT leaders interview and observe frontline staff to understand how it fits with clinical workflow, while half of clinical leaders do so. And, few respondents include care team members (only 26 percent) and patients and family members (16 percent of IT leaders and 4 percent of clinical leaders) in the selection and implementation process.

Clinical IT systems have to deliver on a host of outcomes, ranging across quality, safety, efficiency, and experience. Clinical and IT leaders are focused on all of these measures, as well as technical and implementation metrics. When asked how they measure the success of clinical IT solutions, the respondents said:

Clinical measures – 72 percent of IT respondents, 83 percent of clinical respondents

Efficiency measures – 60 percent of IT and 61 percent of clinical

Experience measures –47 percent of IT and 70 percent of clinical

Implementation measures – 63 percent of IT and 65 percent of clinical

Technical measures – 54 percent of IT and 63 percent of clinical

However, clinical and IT leaders agree that the ultimate measure of clinical IT solution success is the impact solutions have on clinical measures such as quality and safety improvement (39 percent of IT respondents and 46 percent of clinical respondents).

Clinical and IT Burnout

The clinical leader survey respondents were also asked about clinician burnout and whether clinical technology and related documentation requirements are key factors. While the issue of technology as a factor in burnout among doctors, nurses and care team members has received a lot of attention, clinical respondents in this survey were actually split about IT’s role in burnout—44 percent cited clinical IT as a significant contributor to burnout, while 44 percent said it is a minor contributor. Further, 9 percent said clinical IT doesn’t contribute at all. Three percent said that clinical technology helps to alleviate clinician burnout.

The report also found that the majority of clinical leaders (76 percent) believe that collaboration between IT and clinical teams to ensure clinical technology improves workflows is key to turning clinical IT into a burnout solution rather than cause. They also point to the importance of system integration to ensure IT solutions work together, cited by 69 percent. More than half believe that workflow and rules engines help prioritize relevant data and tasks (59 percent), and that communication and collaboration platforms help ease the burden of team-based care (52 percent).

On the IT side, the report explored whether the pressure of supporting clinical IT solutions is affecting IT team members. The IT leaders who participated in the survey were asked to what degree are IT teams/IT leaders burned out by the demands of supporting clinical IT selection, implementation and management. Half of IT respondents reported that their teams are somewhat burned out by the demands of supporting clinical IT selection, implementation, and management. Only 9 percent reported not being burned out at all, with the rest being moderately burned out (33 percent) or extremely burned out (9 percent).

Two-thirds of IT respondents (64 percent) cited budget and resource restraints as the top factor contributing to burnout among their teams. Other roadblocks included difficulty working with clinical teams (20 percent), lack of opportunity to do innovative work (17 percent), the pressure of running IT on which lives depend (14 percent), and lack of understanding or support from executive leadership (12 percent).

The report authors concluded the report by noting that while IT and clinical leaders have laid strong foundations for a collaborative approach, there is an opportunity to go further, for example by encouraging more direct engagement between IT and frontline caregivers.

“Successful adoption of technology for clinical collaboration and workflow depends on deeply understanding the context in which frontline caregivers work, and enabling the outcomes they expect. These outcomes include factors related to quality and safety, such as reducing adverse events and injuries, and being responsive to patients. They also include factors related to clinician satisfaction, healthcare quality, and hospital efficiency,” the report authors wrote.

Further, the report authors assert that burnout also has bearing on safety and quality. “The results show that while burnout is a more significant issue for clinical leaders, their IT colleagues are not immune. Greater collaboration between the two groups when selecting and implementing clinical IT systems can play a key role in relieving the burden,” the report authors stated.

Among the survey respondents, 88 percent were from hospitals with more than 100 beds, 15 percent from hospitals with 101-250 beds, 17 percent from hospitals with 251-500 beds, and 56 percent from hospitals with more than 501 beds.

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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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