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Report: Despite Widespread Usage, Docs Relatively Dissatisfied with EHRs

August 29, 2016
by Rajiv Leventhal
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Medscape’s latest health IT report reveals the latest trends and challenges with EHR usage across the U.S.

Very few physicians these days operate their practices without an electronic health record (EHR), but satisfaction levels with the technology have dropped some, according to Medscape’s EHR Report 2016.

For the report, Medscape surveyed more than 15,000 physicians across more than 25 specialties this summer, asking about usage, specific system ratings, and vendor satisfaction. Indeed, in the survey, more than 91 percent of physician respondents said they use and EHR. Two percent of respondents are currently installing or implementing an EHR, and 3 percent plan to purchase or start using an EHR within the next two years, meaning that it won't be long before nearly every physician is using an EHR.

This is compared to Medscape’s 2012 report, which revealed that 74 percent of participating doctors said they were currently using EHRs, and another 20 percent were either in the process of installing/implementing an EHR or planned to purchase or start using one in the next two years. Further, the 2016 report found that more than two-thirds (68 percent) of physicians use a hospital or health EHR system, whether they work within these systems (63 percent) or are in independent practices that use them (5 percent). A third of independent practices have their own system, the data showed.

While physicians certainly have many complaints about EHRs, they also recognize the positive effects of having one, according to the report. Over half (56 percent) of respondents said that EHRs improve documentation, and just under a third believe that they improve patient service (30 percent), clinical operations (32 percent), and bill collections (31 percent). On the flip side, 21 percent of physicians said that EHRs have made the documentation process worse, and 25 percent cited detriments to patient service and clinical operations. Only 7 percent said they make the collection process worse.

To this end, since the 2012 Medscape survey, satisfaction rates have dropped a bit. This year, 41 percent of physicians said they were somewhat to very satisfied, compared with 45 percent in 2012. The difference over the past four years regarding physicians who were somewhat to very dissatisfied is even more pronounced: 27 percent in 2016 versus 21 percent in 2012. But, despite relative dissatisfaction with most EHR systems, 81 percent of physicians plan to keep their current EHRs. And although 17 percent plan on switching, only 5 percent cited dissatisfaction as their reason.

Also in this year's report, 57 percent of respondents said that EHRs reduce face-to-face time with patients, and 50 percent noted a reduction in the number of patients they can see. Still, this is better than the corresponding percentages reported in the 2014 survey—70 percent and 57 percent, respectively.

Regarding the highest rated and most widely used EHRs, in 2012, Epic was the most widely used EHR (22 percent) and was still on top in 2016 (28 percent). However, there was a big change in the second spot. In 2012, Allscripts held that position, at 10 percent, but in 2016 it didn't even appear in the top five. Possibly this was fallout from the 2012 decision to drop its small-practice software, MyWay, because of design flaws that prevented users from meeting meaningful use requirements, the report’s authors concluded.

Further, EHR systems typically differ between large institutions, such as hospitals, and independent practices. Those used in larger organizations require complex networks and software to manage more activities, more specialties, and more reporting than typically needed in independent practices. Epic dominates the EHR market for hospitals and health systems, with 41 percent of users—more than three times as many as Cerner (13 percent), its next largest competitor. All other EHR systems were each used by 2 percent to 6 percent of hospitals or health networks. Of note, about 5 percent of independent practices use hospital or health network systems and were included in these responses.

For independent private practices with their own EHRs, including many smaller practices, generally use a different set of products. eClinicalWorks was rated first in usage (12 percent), and Practice Fusion and NextGen tied for second place, with 8 percent each.

Survey participants were then asked to rate their EHRs by several key criteria, including ease of use, vendor support, overall satisfaction, connectivity, and usefulness as a clinical tool. The scale used in this report is 1 to 5, where 1 equals poor, and 5 equals excellent. Individual ratings were then averaged to come up with an overall score. The systems in this chart include both hospital- and small practice–based EHRs. The Veterans Affairs Computerized Patient Record System (VA-CPRS) received the top rating (3.7) while, interestingly, at the bottom of the list (2.7) was AHLTA, the EHR used by medical providers in the US Department of Defense. The VA system was also rated first in the 2014 report; Epic, which is in second place this year, did not appear in the top five in 2014. Among independent practices using their own EHR systems, Epic was also in first place with a score of 3.5.

For the ease of use category, Amazing Charts and Practice Fusion, which are used in independent practices, were highest rated at 3.9 and 3.7, respectively. Meanwhile, the two EHRs with the highest satisfaction rating (tied at 3.8) were again Practice Fusion and Amazing Charts (used mostly in independent practices). This criteria includes not only staff and overall satisfaction, but also value for the money and the usefulness and appearance of the patient record.

Regarding exchange of information, Medscape asked about EHR connectivity across four domains: with diagnostic devices, practice management, reference and hospital labs, and for supporting referrals. All of the top five responses are systems for large networks: VA-CPRS (3.7), Epic (3.6), Cerner (3.1), athenahealth (3.0), and AHLTA (2.9). But it also should be noted that most scores were below average, with many of the small-practice systems leaning toward "poor" on the scale.

What’s more, nearly two thirds (62 percent) of physicians found e-prescribing to be most helpful EHR feature, and 57 percent indicated being able to locate and review patient information more easily. About half (49 percent) cited incorporating lab results, allowing for drug/allergy checks, and enabling other physicians to access patient records.

Additionally of note in the report is the highly controversial copy-and-paste functionality in EHRs, which attorneys say creates a host of problems. Interestingly, many physicians say it's a necessary practice in order to move through their day, according to the report. And indeed, 31 percent of physicians often copy and paste, 11 percent always do so, and 24 percent do so occasionally.

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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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