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A Rural Healthcare Report Examines Physician Shortage Issues in Nebraska

April 16, 2018
by Mark Hagland
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A new report on rural healthcare looks at the physician shortage in Nebraska, and some of the alternatives, around mid-level professionals, that are emerging in order to address that ongoing shortage

A 2018 rural health care workforce report issued by the University of Nebraska Medical Center reveals that while there has been an 11 percent increase in the number of physicians in the state over the last 10 years, there are 13 counties that still do not have a primary care physician, according to a press release published by the University of Nebraska Medical Center.

According to the April 4 press release, that finding was one of a number of key findings that appeared in a the 64-page report, "The Status of the Healthcare Workforce in the State of Nebraska,” published this month. "The health care workforce is an essential component in making Nebraska the healthiest state in the union and timely and accurate data such as this report will help inform initiatives and policies to help address those challenges," said Jeffrey P. Gold, M.D., UNMC Chancellor, in a statement included in the press release.

The study was commissioned and funded by the Nebraska Area Health Education Center Program (AHEC) and used the most recent data from the UNMC Health Professions Tracking Service and the state of Nebraska.

"This report helps to measure the progress we have made in the state in dealing with some of the workforce issues in rural Nebraska and in planning for the future," said Mike Sitorius, M.D., professor and chair of family medicine in the UNMC College of Medicine.

"Some programs have helped increase the number of rural health professionals, but there still exist substantial recruiting challenges to bolstering the health workforce and access to health care in rural and underserved areas," said Fernando Wilson, Ph.D., acting director of the UNMC Center for Health Policy and lead author of the report.

Among those challenges, the report found these:

  • The reality that nearly one-fifth of physicians in Nebraska are more than 60 years old, and thus likely to retire in the near future;
  • 18 of 93 Nebraska counties have no pharmacist; and
  • Demographics in many counties are becoming more diverse, but the current health workforce doesn’t necessarily reflect the populations being served.

"In partnership with stakeholders from Scottsbluff to Omaha, we’ve made progress over the years. But the landscape of health care is rapidly changing, and we must remain diligent to sustain the progress we’ve made and close the gaps," Dr. Wilson said, in his statement in the news release.

Dr. Wilson led a nine-person research team representing several professions from UNMC and with input from Thomas Rauner, director of the primary care office in the Office of Rural Health for the state of Nebraska.

Interestingly, one inevitable response to the ongoing physician shortage in Nebraska has been that, “Since 2007, there has been a large increase in the number of active physician assistants (PAs) in the state,” the report noted. “There are 908 PAs (or 47.3 PAs per 100,000 population) versus 598 (33.5 {As per 100,000 population) in 2007—a 52-percent difference in number of PAs. PAs currently provide a total of 35,878 work hours, equating to 897 FTE PAs. Half of the PAs are 40 years old or younger, and over 70 percent of PAs are female.” Further, the reported stated, “Analysis of the distribution of PAs by county showed that 16 counties in Nebraska do not have an active PA.”

Meanwhile, the reported noted that, “In 2017, there were 1,148 nurse practitioners (NPs), 36 certified nurse midwives (CNMs), 49 clinical nurse specialists (CNSs), and 308 certified registered nurse anesthetists (CRNAs). The number of NPs rose from 767 to 1,148 in 2007-2017—a 50-percent increase. For CNMs, the increase was from 22 to 36 professionals.”

In their concluding section, the authors of the report noted that “The State of Nebraska has historically faced substantial challenges in maintaining access to healthcare in rural communities. Despite the importance of reducing rural-urban disparities in the state, a comprehensive study of the distribution of Nebraska’s healthcare workforce has not occurred since 2009. Our study uses recent data on numbers and work hours of licensed and active providers to provide a demographic profile of the current workforce.”

Importantly, the report’s authors state, “Our results highlight the substantial deficit in the supply of physicians across counties in Nebraska, particularly for the primary care specialties of internal medicine, OB/GYN and pediatrics. In addition, nearly one in five physicians in the state are older than age 65, and thus are likely to retire in the near future. In contrast, the number and rates of physician assistants and nurse professionals have grown substantially over the last decades and provide wide-ranging geographical coverage in Nebraska. The greater reliance on physician assistants and nurse practitioners,” they wrote, “has helped to offset the inadequate supply of primary care physicians. Legislative Bill 107 (passed in 2015) grants full practice authority to Nebraska nurse practitioners, so that they are now able to provide the full scope of services for which they are trained and educated. This legislative change will significantly enhance access to care in rural and underserved areas within Nebraska. However,” they noted, “there remains substantial variation in the rate of nurse professionals across the state, with relatively low numbers of RNs, LPNs and APRNs in west and central Nebraska.”

 

 

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The Evolving Healthcare CIO: Innovation Over Information

November 15, 2018
by Rajiv Leventhal, Managing Editor
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The pressure is on CIOs and others in the health IT C-suite to become organizational leaders, while delivering in ways different from ever before

The healthcare CIO is the correct initialism for “chief information officer,” but as the landscape continues to shift—with the focus now on digital and strategic optimization, transformation and innovation—some observers are now wondering if “information” is really the most appropriate word for all that encompasses the modern-day CIO.

For the past two decades, Chuck Podesta has been a healthcare CIO, spending the last four years at UC Irvine Health, the integrated health system at the University of California-Irvine in Orange County, California. Podesta recalls the days when the CIO had a more IT-based title and financially-related job in healthcare, since clinical IT wasn’t a strong focus at that time. But with the evolution of EHRs (electronic health records), says Podesta, “The focus became clinical and the job suddenly had a broader scope. It’s not just the day-to-day running of the systems anymore; the CIO is now needed from the standpoint of strategy development because he or she is affecting the entire organization.”

Some would refer to the early-day healthcare CIO as an IT engineer of sorts, someone very technology-focused whose core responsibilities centered around hardware and software implementations, and getting servers up-and-running within the organization. Then came the influx of EHR deployments across hospitals and health systems, and now that there is near-universal possession of EHRs in U.S. hospitals, the tide is once again shifting.

“In the past, the CIO had more of a technical role and the focus was more on the operational side of the house—things such as enterprise resource planning (ERP) and the billing cycle. But the widespread advent of EHRs changed so much of that,” says Dave Levin, M.D., a former chief medical information officer (CMIO) at Cleveland Clinic and current chief medical officer at health technology company Sansoro Health. “When you deployed the EHR, it tightly linked clinical operations to IT. And that’s obvious. But it also put IT in the middle of enabling all kinds of activities and strategies. So, this requires strong enterprise governance and strong IT governance, and it requires that they fit together. A lot of organizations are struggling with that, and that’s reflected in the role the CIO plays,” Levin says.

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Podesta notes that when the CIO title first came about, many directors of IT in healthcare organizations wanted the “chief” designation. But to Podesta, there was a key difference between IT directors and CIOs:  good directors of IT spend 80 percent of their time managing day-to-day operations and 20 percent of their time on strategy, but for “true” CIOs, it’s the opposite, he says. “There was a period where there was a ‘filtering out’ of individuals who tried to become CIOs, but were really IT directors and couldn’t make that leap into the strategy world. That led to a changing of the guard,” he says, adding that much of the new focus turned to developing EHRs and then becoming an equal player in the C-suite on the strategy teams. “You have to be able to work on IT strategy and develop it in conjunction with the business strategy,” Podesta attests.

Today’s CIO—One of the Scariest Jobs in Healthcare?

For the modern CIO, priorities are indeed changing and becoming more complex, and with that comes increased pressure. For instance, in addition to all of the technical aspects of the job, today’s healthcare CIO must also stay out in front of various up-and-coming health IT innovations, while maintaining a much-needed big-picture view of how digital transformation will affect business operations.

And then there is the cybersecurity factor; a 2016 survey of 100 healthcare CIOs from Spok and the College of Healthcare Information Management Executives (CHIME) revealed that 81 percent of CIOs said strengthening data security was their top business goal for the next 18 months. Put all together,

“The CIO role in healthcare is one of the scariest roles there is because of the high risk involved, and the fast pace of technology,” offers David Butler, M.D., founder of healthcare consulting firm Calyx Partners, and a former clinical IT executive at Sacramento-based Sutter Health. “The cost of healthcare IT has gone up tremendously. [The days of] just buying Epic’s EHR and having your job be safe are long [gone],” Butler adds.

Butler notes that an EHR go-live, and the optimization that follows, are typically the most transformational things that occur in a CIO’s life, and the audience for these deployments are what he calls the CIO’s "golden geese”—physicians and nurses. “So there is more pressure on the CIO than ever before,” Butler attests. He adds that in addition to all of the clinical and IT considerations, it’s unfair to expect CIOs to be privy to all of the regulatory requirements that come from CMS (the Centers for Medicare & Medicaid Services) as well. “There is just no way that CIOs can know all these things. I think expectations need to be reset,” Butler says.

New Considerations

As such, experts believe that the “new” healthcare CIO must have a broader understanding of healthcare. “Smart organizations are looking for a more strategic role for the CIO, and think that they should be in the C-suite and in the middle of strategy discussions,” says Levin. "CIOs need to understand both where the organization is going—so that they can think about the technology that can enable that [vision]—while also informing and expanding on the thinking of the folks that are considering strategy—things that might not have been considered without that [CIO] expertise in the room,” he adds.

A core part of a healthcare organization’s vision going forward will certainly involve strategies on transitioning to a value-based care environment. Indeed, the emphasis on accountable care has increased the need for hospitals and health systems to collect and analyze data to drive improvements in quality and efficiency—leading many hospitals to ask more of their CIOs.

To this end, Podesta notes that the industry has been operating in a fee-for-service world for so long now, and in most cases, IT is an enabler of the business strategy, so once the business strategy starts to move toward value-based care, IT needs to come into play from a strategy perspective. “If you don’t have that background or the ability to understand it, you will be left behind,” he attests.

Podesta adds that in some instances, he is seeing CIOs play in both the medical provider and payer world, since lots of healthcare systems also have their own insurance companies. “You will see more and more of that in the future, and as a CIO, you will need to understand what risk means and how to manage risk,” he advises. “It’s a completely different way of caring for patients, and being able to sift through all the technologies out there for your organization, without making huge mistakes and spending the money in the wrong place, will certainly be a challenge,” he adds.

What’s more, all the sources interviewed for this article were quick to point out yet another new business consideration for CIOs: the influx of non-traditional players looking to move into healthcare. Podesta brings up the new Apple Health Records feature that allows patients of hundreds of hospitals and clinics to access medical information from various institutions organized into one view on their iPhone. “Lots of organizations are signed up for [this], and we have actually started to create apps; five years ago, you wouldn’t have been thinking about that. But now you have to model your organization to make sure you have the people to utilize these technologies as they are coming out,” he says, adding that hiring the right people who can work in these environments will be crucial. “The time for the sequel programmers is coming to an end. You need data scientists now.”

And as Butler bluntly puts it, “Apple, Amazon, Google and Microsoft have been watching this $3 trillion [healthcare] prize for a long time, but have not touched it because of HIPAA and other over-regulated [barriers] that prevented them from innovating in this space. But then you had deductibles go from $1,000 to $7,000 before the insurance kicks in, so the patient turned into the customer. And these disruptors said to themselves, ‘We know customers, we don’t know patients. So now we will go for it.’”

The CIO-CMIO Partnership

As CIOs continue to take on more responsibilities, experts believe that another clinical IT role in the C-suite, chief medical information officers, or CMIOs, are also ready to take on an increased role, especially as IT becomes much more critical to support value-based care and other quality initiatives. Indeed, as CMIOs have become more engaged in healthcare organizations, the interaction between these key IT players is expanding and continuing to evolve.

Levin recalls that in the early days of EHR deployments, folks saw the CMIO as the person that should go deal with the “angry physicians.” But now, post-deployment, as the tide turns to thinking about getting the most out of these IT systems, the partnerships between CIOs and CMIOs are stronger and more equal, Levin says.

“You are even seeing CMIOs migrating into the CIO role, which was rare in the past, but becoming more common. You are also seeing CMIOs migrate into other C-suite-type roles such as chief health information officers, chief quality officers, chief transformation officers, and in some cases, chief medical officers. And that makes sense, since there is an increasing emphasis on the intersection of clinical and operational, and the role of IT in supporting all of that,” he says. Podesta agrees with Levin’s premise; quite a few  CMIOs are becoming CIOs, he notes. “A lot of them have gone back and gotten MBAs to understand the business side [of healthcare].”

Podesta is also seeing another trend: that some organizations, such as academic medical centers, are struggling with clinical IT, and are thus recruiting for CIOs who are physicians, to get a level of credibility with doctors to help them with issues around physician adoption and EHRs. “I get lots of calls from recruiters, and when I talk to them about different positions out there, many are looking for clinically-oriented people. I am seeing that more and more,” he says.

To some, the evolution of the CIO-CMIO relationship also paints a bigger picture of just how tightly linked everything has become—particularly the dependency that a healthcare organization has on IT for its success. “It’s never been greater,” says Levin, who believes that the CMIO “is a unique beast, and one of the few healthcare roles in which you sit at a crossroads and have a view of the world that is different from other C-suite leaders.” He adds, "And that view might not be better; it’s complimentary. The typical CMIO has practiced clinically, has been involved in IT, and many have had operational backgrounds as well, or a medical affairs background. They are kind of ‘unicorns’ in a way, and I think they match up nicely with the way the governance and strategic needs of the organization overlap,” he says.

What the Future Looks Like

In a myriad of different ways, it’s been quite the evolution for CIOs, CMIOs and others in the healthcare IT C-suite. With all of the challenges and increased pressure that experts believe have mounted in recent years, comes opportunity for certain individuals to thrive.

Levin says the qualified CIO going forward will need the necessary “soft skills,” leadership ability, and strategic knowhow. It will be less about the technical aspects of the role. “The ultimate challenge everyone is facing is the pursuit of the Triple Aim and doing it efficiently, so a lot of the [job] is about how you can do more with less,” he says.

These roles also have another kind of unique balancing act, in that so many of them try to maintain a clinical practice, which Levin notes “is admiral,” but because they have also taken on these important administrative and leadership roles, he has seen many of his colleagues struggle with the balancing act. “Too often, they think the clinical/administrative ratio is 50:50, but in reality, it’s 75:75 and they are working at 150 percent capacity,” he says.

Adds Podesta, “It’s not just understanding the IT world—the programming and the infrastructure—but you have to understand the business side as well. To be in that C-suite and in those meetings, you need to be able to add value to items that maybe aren’t under your control. But you need to be that thought leader within the C-suite—just like the chief operating officer, chief medical officer and others are.”

Podesta believes that the “information” part of the chief information officer title is simply no longer indicative of all the CIO must do now, and what will be required of the role moving forward. “People view the CIO role as ‘you must work in medical records’ or even that you are in marketing, so yes, I think we probably do need a better title,” he acknowledges. Podesta notes that titles such as chief digital officer are making the way into healthcare organizations, and given the digital landscape, it’s actually more appropriate. “The CIO might move to ‘chief innovation officer,’ and that makes a lot of sense,” he says.


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Vanderbilt Announces Health IT Leadership Transition

November 6, 2018
by David Raths, Contributing Editor
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Patel to succeed Johnson as leader of VUMC HealthIT

Vanderbilt University Medical Center HealthIT has announced a change of leadership. In January 2019 Neal Patel, M.D., M.P.H., who has been VUMC’s chief health information officer, will succeed Kevin Johnson, M.D., M.S., as HealthIT leader.

HealthIT’s responsibilities include informatics support for a broad scope of VUMC’s health system demands. Tools supplied and supported through HealthIT help enable VUMC to achieve its strategic objectives within the clinical, educational and research enterprises.

Johnson, Cornelius Vanderbilt Professor, will continue to serve as chair of the Department of Biomedical Informatics (DBMI). A professor of pediatrics, he joined the Vanderbilt faculty in 2002 and has been chair of the DBMI since 2012. He was named Senior Vice President for Health Information Technology in 2014.

During his tenure, Johnson served as leader for the multi-year, system-wide effort to replace its homegrown EHR with Epic, which went live in November 2017. Patel joined Johnson as co-lead during the Epic launch.

Through this leadership change, Patel will now report to John F. Manning Jr., PhD, MBA, Chief Operating Officer and Corporate Chief of Staff. “With Dr. Patel succeeding Dr. Johnson in this role, there is an assurance of continuity as we move forward. With our Medical Center and health system at an important inflection point, and in a period of significant growth, I want to express my appreciation to Neal for assuming these new responsibilities,” Manning said in a prepared statement.

Patel joined the faculty of the Department of Pediatrics in the Division of Pediatric Critical Care in 1997. He was named Chief Medical Informatics Officer in 2006. His responsibilities in this role included leading efforts for translating the Medical Center’s healthcare delivery, quality and patient safety goals into informatics strategies to optimize the delivery of patient care.

 

 

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CHIME’s Russ Branzell: A Tech Revolution is Coming to Healthcare

November 2, 2018
by Rajiv Leventhal, Managing Editor
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The president and CEO of CHIME said at the association’s Fall CIO Forum this week that collaboration and being a community will be key steps to succeeding in the new healthcare

Healthcare CIOs, CMIOs and other top IT leaders are under increased pressure these days for a variety of reasons, and staying out in front of emerging health IT innovations, while maintaining a big-picture view of how digital transformation will affect business operations, are right at the top of the list.

Russell Branzell, president and CEO of CHIME (the Ann Arbor, Mich.-based College of Healthcare Information Management Executives) for the last six years, leads an executive organization which has a membership of a few thousand CIOs, CMIOs and other senior healthcare IT leaders. And with so much happening these days around technology innovation, new entrants into the market—some of which could be seen as potential disruptors—in addition to policy considerations and cybersecurity challenges, associations like CHIME are relied on to drive clinical IT executives in the right direction.

At the CHIME 2018 Fall CIO Forum in San Diego this week, Branzell sat down with Healthcare Informatics Managing Editor Rajiv Leventhal to discuss the challenges and opportunities that lie ahead for CIOs, and what skills will be critical to success going forward. Below are excerpts from that interview.

I am sure you would agree that it’s both an exciting and anxious time in healthcare. What is top of mind right now for your members?

Yes, I think there is a duality to this that is exciting and scary at the same time. There are practical and technical challenges we are being faced with now, with one of the biggest being cybersecurity and the threats and pains in those areas. Organizations are changing to new models [of care], and there is also consumer engagement that is unique to this time period; it’s not the same old game we have always played.

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The most interesting thing coming at them, though, is this next wave of what we refer to as “fourth revolution technology” that’s on the way. So that means 5G [technology], robotics, biosensors, genetic manipulation, and neural networking. These are buzzwords, but the reality is that they are real. Things are coming at us, and we have not been able to deal with at this level of advanced technology before.

What we have done in the past is incrementally gain the existing technology that has been in play in healthcare for the last 30 years. So we are trying to keep the trains on time, advance the organization, help them get benefits realization, and move to a new care model of consumerism and value. But we also see this other thing coming down the track that will dramatically disrupt all this. While it’s a unique time, and a little bit scary, scary is another way to say “great opportunity.”

Is the traditional/current CIO ready for this revolution? 

We have always been able to keep up with the small, incremental learnings. We have had the CIO 2.0 model out for 15 years, and that brought people from the traditional technology environment to driving change in organizations. The difference now is, the new things coming at us will require us to learn at a pace we have never learned at before. There will be disrupters in the industry for us to adapt to and understand at a pace we have never understood before. Undoubtedly, the CIO 3.0, the health IT leader 3.0, and the digital leaders of the future will monumentally change their internal skillsets and how they work.

On the policy front, lots of relevant regulations are set to drop in the next few months. The administration has been aggressive thus far in its proposals for promoting interoperability, but some would argue that fundamental data sharing challenges need to be ironed out first. What is CHIME’s stance on this?

There is still a strong degree of gap between the reality of today and the things that need to be put in place to enable [interoperability]. Some of those things are relative to standards and the universal transport across the country from an information sharing perspective. The government is trying to say there shouldn’t be barriers to inhibiting things that we are being successful in.

San Diego offers a good example in that things are well put in place, health systems are willing to share, I would say that there is no ubiquitous information blocking here, and the organizations generally all want to do the right thing for the patient. So in this micro-environment, though a big city, they do a good job of sharing information and being interoperable with each other.

But now magnify that across California, and it’s a scale issue in which we don’t have in place the universal standards, identification, transport layer, agreements, and multi-state consent. So many things still need to be addressed, whether that’s through administrative rule, law, or presidential order, some things need to be addressed at a macro level to accelerate that last 10 percent. About 90 percent is being done in local environments. Most people don’t often leave their local environment to seek care. But for the 10 percent or so that do, these things are not quite in place yet.

I’ve been interested in reading CHIME’s comments on aligning 42 CFR Part 2 with HIPAA, though this provision was not passed in the recent opioids package. Could this be reconsidered down the road?   

We were disappointed that it wasn’t [included], but we also considered different areas of statute ownership, within the government, relative to this and we [knew] they had to get [the bill] out. We will still advocate for the alignment in these areas so that we could accelerate solutions and service the people who need the help. This was ubiquitous across all our membership, and this was something that could have been addressed, but what we heard was, and I understand this, that they needed to get this out [now], and then possibly the [alignment] piece could be bolted on later.

In this pressured current moment, what advice could you offer to CIOs?

Like never before there is a need for people to hone and advance their skills, and become educated in what’s coming down the tracks as far as advanced technologies, while also getting the solutions they already have in place to higher degrees of success. The answer to all of this will be about us being a community.

We have been successful here at CHIME for almost [three decades] in building this network, building the relationships, and building the trust environment that we need. We need to lean on each other. People do this in small pockets and big pockets, and to survive in the future, we will need to ubiquitously share with each other. You don’t want to have everyone invent and innovate locally; not that we shouldn’t in a micro sense, but in the macro sense, we have to share in ways that we never have before. 

I’ll use opioids as an example. If Anne Arundel [County in Maryland] and Geisinger Health System are the two best in the country [at fighting the opioid epidemic], why would the other 5,000 or so places go and start from square one. That makes no sense whatsoever, but that’s the way our industry has worked for a long time. They key to us solving problems is communication and collaboration.


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