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Senior VA IT Officials Indicate Department Will Transition to Commercial EHR

February 7, 2017
by Heather Landi
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A senior IT official with the U.S. Department of Veterans Affairs (VA) told members of the House Committee on Veterans Affairs during a hearing Tuesday that the department will move to a commercial off-the-shelf electronic health record (EHR) system.

Rob Thomas, II, Acting Assistant Secretary for Information and Technology and Acting CIO, Office of Information and Technology for the VA, testified before House Veterans Affairs committee members during a hearing focused on accessing the VA IT landscape. House Veterans Affairs committee members scheduled the hearing to get a report on progress and challenges related to the VA’s healthcare IT modernization efforts.

The VA is still attempting to modernize the department’s EHR system, the Veterans Health Information Systems and Technology Architecture (VistA), which has been the subject of numerous Congressional hearings. In previous committee hearings in both the Senate and the House, lawmakers have voiced ongoing frustrations about the VA’s progress on modernizing its IT systems and the progress of achieving interoperability between the VA’s VistA and the Department of Defense’s (DoD) EHR system. It has been estimated that the VistA system is at least 30 year old.

President Donald Trump has tapped David Shulkin, M.D., an Obama administration appointee and current VA undersecretary, to lead the Department of Veterans Affairs. Shulkin, 57, a board-certified internist and fellow of the American College of Physicians, is expected to be approved by the Senate Veterans Affairs Committee today.

During the hearing, Committee Chairman Rep. Phil Roe said, “This is the third major attempt to modernize VistA in the past decade. Retaining or replacing VistA is a make-or-break decision for VA and must be made deliberatively and objectively. The VA must judge VistA Evolution realistically against concrete goals. If it falls short, moving the goal posts is unacceptable.”

In response to committee members’ questions about where things stand with the VA’s EHR system, Thomas responded, “I’m comfortable that we’re going with commercial. I can’t speak for Dr. Shulkin, and I’m hoping for a speedy confirmation so that he can come and help us work through that. Knowing his background in the industry and his experience as being a doctor at leading hospitals and I’ve worked with him the past 18 months, he’s very decisive and I’m looking forward to a quick confirmation.”

Thomas also said, “My goal, my charge, is that we go commercial to the greatest extent possible. We don’t have a great track record with developing software.” He did not offer any timelines or schedule for when the department might transition from its homegrown system to a commercial, off-the-shelf system.

Back in August, the VA issued a request for information (RFI) on the Federal Business Opportunities website and requested feedback on transitioning to a commercial EHR system. An initial plan which called for DoD and VA to develop one integrated electronic records system to replace separate systems fell through. After two years of discussions and planning, the VA and DoD announced last year they would forgo plans to build a new health records system to be used jointly by the departments, at a reported cost of $560 million, in order to pursue separate plans.

The Defense Department awarded a multi-billion dollar EHR contract in 2015 to Leidos and Cerner. Although initial deployment was set to begin in December 2016, the contract was delayed and is scheduled to begin this month.

During the hearing Tuesday, David Powner, director, IT management issues, U.S. Government Accountability Office (GAO), testified that in 2015 the VA spent about $3.9 billion to improve and maintain its IT resources, with about $548 spent on new systems development and $2.3 billion on maintaining existing systems and $1 billion on payroll and administration. For 2016, the VA received appropriations of about $4.1 billion for IT, with only about $500 million going to developing or acquiring new systems and about $2.5 billion on maintaining existing systems. “Most goes to operational systems, most of which are old, inefficient and difficult to maintain,” he said. Powner also said interoperability is needed between not only the VA and DoD, but also the VA and private sector providers. “We don’t see evidence that a separate plan [from the DoD] will be cheaper or quicker. DoD is pursuing a commercial solution, while VA is trying to update an aging system. VA is now considering a commercial EHR. This uncertainty is not acceptable; a decision needs to be made. VA needs to let go of VistA and go with a commercial solution. There is no justification for DoD and VA pursuing separate systems,” Powner said.

Thomas agreed that the VA’s IT spending needed to shift. “I’d like to see 60 percent for maintenance and 40 percent for development,” Thomas said.

Several committee members also expressed concerns about the security risks of operating an EHR system that is several decades old. “How many people work in the VA that can do anything on a 50-year old system. Who can work on these systems?’ asked one committee member.

“To your point, the available resources for those aging systems gets smaller ever year, as people retire, and that increases that risk that makes this even more important that we get these legacy systems shut down,” Thomas said.

On the issue of VA's medical appointment scheduling system, Jennifer Lee, M.D., Deputy Under Secretary for Health for Policy and Services, Veterans Health Administration, assured committee members that the department was moving forward with its commercial scheduling system, referring to the Medical Appointment Scheduling System (MASS) contract awarded in 2015 to Systems Made Simple, a subsidiary of giant defense and national security contractor Lockheed Martin, and Epic Systems. The VA is currently running a pilot project and results will be available in 18 months,  Lee said. In the meantime, VA must continue developing an interim system, known as the VistA Scheduling Enhancement (VSE) project. A “go/no-go” decision on rolling out the VSE nationwide is set for Feb. 10, Thomas said.

Regarding interoperability with DoD and community healthcare providers, Lee highlighted the VA’s health data exchange efforts through the eHealth Exchange, a health information exchange network supported The Sequoia Project. According to Lee, through the eHealth Exchange, the VA has 88 community partners, representing 815 hospitals, 435 federally quality health centers, 150 nursing homes, 8,000 pharmacies and 14,000 clinics.

Lee also said the VA’s current data exchange is an “opt-in” model but she would like to see a statutory change to enable an “opt-out” model to increase the number of veterans’ patient records that can be shared with other healthcare providers.

 

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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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