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    Meaningful use essentially digitized the healthcare system arguably faster than any other sector of the U.S. economy. But as with so many federal government programs, laws, rules and regulations, that is not even close to suggesting the endeavor was an indisputable success.

    Could the total $37 billion paid out thus far, according to newest summary report CMS posted, have been spent more wisely? Did the program succeed or fail? Perhaps the most critical question right now is: looking to the future what should the federal government’s role be?

    “We believe that now is the time to step back and recalibrate the role of the federal government on the basis of lessons learned,” John Halamka, MD, and Micky Tripathi wrote in an article in the New England Journal of Medicine. 

    Both Halamka, CIO of Beth Israel Deaconess Medical Center, and Tripathi, CEO of the Massachusetts eHealth Collaborative, have been involved with the Office of the National Coordinator for Health IT’s work fostering the meaningful use EHR incentive program.

    Tripathi and Halamka put forth four suggestions for the government’s role moving forward: dramatically simplify the Merit-Based Incentive Payment System to focus on interoperability and streamline quality measures; overhaul EHR certification to focus exclusively on interoperability; encourage interoperability by action not by regulation; and, lastly, incentivize the use of application programming interfaces such as FHIR.

    Halamka and Tripathi acknowledged that meaningful use “accomplished something miraculous” in digitizing the healthcare system since HITECH Act passed in 2009. But that rapid transformation also created burdensome regulations and usability, workflow, innovation, interoperability and patient engagement deficiencies.

    “We lost the hearts and minds of clinicians. We overwhelmed them with confusing layers of regulations. We tried to drive cultural change with legislation. We expected interoperability without first building the enabling tools,” Halamka and Tripathi wrote.  “In a sense, we gave clinicians suboptimal cars, didn’t build roads, and then blamed them for not driving.”

    Former national coordinators Vindell Washington, MD, Karen DeSalvo, MD, Farzad Mostashari, MD, and David Blumenthal, MD, wrote in a companion NEJM article that physicians wound up shouldering much of the burden.

    “Many are frustrated by poor EHR usability and the lack of actionable information generated by these systems. In part, such limitations are attributable to the decision to allow proprietary standards and data blocking in the market, which has led to suboptimal data sharing,” they wrote. “As former national coordinators for health IT, we believe that the culture surrounding access to and sharing of information must change to promote the seamless, secure flow of electronic information.” 

    There are no easy fixes when it comes to culture change, in general, and the health IT realm, interoperability specifically, is no exception.

    The former national coordinators called for national standards, APIs, both market innovation and government policies, the emerging Public Health 3.0 model, and various stakeholders continuing to work together.

    “The HITECH era was an important catalyst for EHR adoption, and the industry benefited from government intervention,” Halamka and Tripathi wrote. “If the post-HITECH era can return control of the agenda to customers, developers, and multistakeholder collaborations, we should be able to recapture the hearts and minds of clinicians.”

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    Hurricane Harvey ravaged Texas. Mass flooding forced people from homes, while the death toll has reached 70 people.

    But the disaster also took its toll on the region’s healthcare sector causing disruptions in services or closures of major hospitals like MD Anderson Cancer Center and East Houston Regional Medical Center.

    Stories have already come out about how lingering hurdles to health record interoperability made caring for Houston’s population much more difficult in the wake of Harvey. While displaced patients and emergency situations increase the need to have medical history and allergies at the point-of-care, many providers had difficulty getting that data.

    However, some providers were able to keep operations running. Their stories highlight not only why interoperability needs to become an essential function of healthcare, but how cloud-based system architecture really proves its worth when a disaster strikes. 

    VillageMD Houston

    For VillageMD Houston -- a primary care practice that works with more than 100 Houston-based providers, and partners with clinics, care management services and others, a lot of the essential communication began long before Hurricane Harvey hit the region.

    “Even before a storm like Harvey, we were working on identifying high-risk patients and connecting them with providers and the rest of our team, like care management,” said VillageMD Houston Chief Financial Officer Dan Jenson.

    With high-risk patients, there’s a need for more touch points. Jenson said that his team discussed past storms to determine possible scenarios, which were communicated with patients before the storm.

    Prior to Harvey, the portal could connect to about 10,000 patients. Jenson reached out to athenahealth and overnight, the team was able to create a solution that allowed VillageMD Houston to contact all of its 160,000 patients.

    The platform enabled providers to phone, text, email or message patients about the status of its clinics and provided patients a direct line to physician support.

    VillageMD Houston’s care management team leveraged its list of high-risk patients, and reached out to these patients before the storm to help them prepare and informed them who they could call.

    “We’ve had great feedback from patients that this service provided a voice of comfort before the storm,” said Jenson.

    Further, VillageMD Houston’s Village At-Home program sends providers to the homes of patients who have difficulty making it into the office. After the storm, this program allowed physicians to go into the homes of these patients to ensure they were safe.

    Equipped with tablets from its EHR vendor athenahealth, providers were able to document patient visits, said Jenson. Providers reviewed the needs of the house and determined whether it was safe for a patient to stay there.

    Phone lines remained up during the storm, and Jenson said physicians were on-call throughout Harvey to order x-rays and treat symptoms over the phone. And since the athenahealth platform is cloud-based, these physicians could access patient records from home using mobile devices -- even if they lost power and Wi-Fi during the storm.

    VillageMD also used smart sheets to make sure safe was staff and adjust staffing so staff was able to head to work based on where they lived -- rather than where they were normally employed, said Jenson. The cloud-based platform let staff use the EHR system as normal, even at alternate sites.

    Further, VillageMD Houston worked with providers throughout Houston after the storm. Some practices were overcrowded and others were solo providers wanting to join a larger group. But what remained most important to Jenson was that all patients received efficient care and those in high acuity weren’t left to deal with problems on their own.

    “Only one of our clinics took on water, and a few had water damage. One took on a couple of feet of water on the first floor, but still opened last week despite that,” Jenson said. All clinics are now back up and running, but there is still lingering damage to some clinics and the homes of some staff.

    But to Jenson, as the flooding and physical damage subsides from the city, it’s important for VillageMD Houston to remain in contact with patients.

    “We want to make sure the patients understand there are many lingering health issues that can occur because of the storm,” said Jenson. “We’re sending communications for patients to see providers and get checked out.”

    Advanced Diagnostics

    For Advanced Diagnostics Hospital and Clinic, storm preparation started a week and half prior to Harvey touching down. The provider used checklists and went through normal hospital routine to make sure generators were fully operational, alternative power and internet sources were at the ready and that there was enough food storage.

    According to Rob Turner, CEO and COO of the hospital, he met with the past owners and determined it was unlikely flooding would be an issue. And so the organization was confident the hospital would be fine. They were lucky, and it benefited not only their patients, but patients from other providers after the storm hit.

    “While others suspended service, we were doing normal operations,” said Turner. “We had the comfort of keeping patients in-house. We used our in-house EHR and moved forward, based on appropriate preparation.”

    Preparation starts when you open the hospital, but heightens right before the storm,” said Lucky Chopra, MD, CEO of parent company Advanced Diagnostics. “We’re pleased our systems worked and our dedicated allies and vendors performed for us. It was one less worry.”

    While other hospitals struggled because “their EMR simply couldn’t perform or there was flooding,” things went as planned for Advanced Diagnostics.

    Turner attributed that success to planning, but also to athenahealth’s cloud-based platform. Not only did providers leverage the on-site interoperability, Turner said he was able to log onto the system from home and monitor care and check accounts to ensure that everything was functioning as normal.

    “The system was stable throughout: We had no disruptions in care,” said Turner. “Even with a few bumps in power, our generators kicked on and everything remained intact.”

    “With a cloud-based system, all of our data was preserved in real time,” said Chopra. “And we had no data loss.”

    So much so, that Advanced Diagnostics was able to help other providers in the area, including the AHCA East Houston Regional Medical Center that had 12-inches of flooding. As a result, Chopra said the hospital had to handle patients with higher acuity than with normal operations.

    But due to the tech and hospital functioning as normal, Advanced Diagnostics was able to help East Houston and other local providers by providing care to patients and space for providers to work.

    While their cloud-based EHR meant existing patient records were easy to access, for influx of patients from other hospitals, they had to rely on their dictated history, said Chopra. Fortunately, as new patients came through the emergency room, there was no need to refer to past diagnostics.

    “For most ER traffic, what you see is what you get. And you manage it accordingly,” said Chopra.

    More work to be done

    While Houston boasts some of the top healthcare institutions in the country, in terms of connectivity, the region isn’t where everyone else is in the industry, said Chopra. “But these problems existed before the storm.”

    Most of the time with new records requests, it’s a lot of manual processes, explained Chopra. If we needed records, it would come on a disc. We’re pretty restricted city-wide. But within systems, it’s a lot better. Although there are even inconsistencies within some systems.

    “One of the challenges is because patients don’t move through the system with a full record,” said Jenson. “We had patients come in from other clinics that had shut down… and it’s a burden administratively.”

    “It’s one of the challenges we face, especially during a time like this with patients displaced,” he added. “Some patients come in with limited medical history, others bring files and some don’t, and we have to start from scratch. It takes a long time to gather the necessary information.”

    While VillageMD Houston was able to leverage an iPad solution that allowed patients to get the key information into the system -- “letting providers focus on care rather than just entering patient data into the EHR,” said Jenson.

    “We should not wait to crisis to demonstrate the need for patient-centric backbone, and patients should be able to have control of their data,” said athenahealth Chief Product Officer Kyle Armbrester. “It’s a wake-up call for the industry to break down the barriers between systems, and make sure we’re sharing the most up-to-date data.”

    “We desperately need this industry to move into a modern tech era, where more things are in the cloud and more stable,” he said. “Moving to a modern 2017 infrastructure for healthcare is moral imperative.”

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    Even in the midst of a storm, healthcare providers are responsible for ensuring medical services continue. So, as Hurricane Irma looms off of the coast of Florida, and Hurricane Jose close behind, it’s imperative hospitals not only plan to weather the storm -- but also ensure patient safety in the aftermath.

    Communication was top of mind for VillageMD Houston, which was able to remain open during Hurricane Harvey by using its cloud-based EHR -- and by zeroing in on patient needs.

    “Most importantly -- connect with your patients. Having a plan for getting communications out to patients prior to any potential storm is key,” said Dan Jenson, CFO of VillageMD Houston. “Inform them of the best way to contact you during an emergency and where to turn for care once the storm passes.”

    “This is imperative as resources may be scarce,” he said.

    For Advanced Diagnostics Hospital and Clinic in Houston, its storm preparations were put to the test with Harvey. To its CEO and COO Rob Turner, safety of patients, staff and providers were imperative as the hospital determined how to keep operations up and running during the storm.

    The first step is to make the decision early on whether the provider should remain open or evacuate. Turner said the media can often generate a lot of hype when major storm systems hit, so it’s critical for providers to rely on solid data sources, such as the National Oceanic and Atmospheric Administration.

    NOAA provides weather forecast tools and satellite views that follow the storm and its path.

    Once the organization determines whether to keep operations running, providers need to review their disaster preparedness plan and test staff by running drills, explained Turner.

    No matter the size of the organization, much of the preparedness checklist is the same: food and water supplies, reliability of power sources and test phone and internet connections.

    “The unfortunate nature of disasters like Hurricane Harvey and Irma is that nothing can truly prepare you for the weather that might ensue,” said Turner. “Because we are on a cloud-based IT system, we weren’t concerned with servers or access to patient data, but for some facilities, it’s a critical concern.”

    Turner recommends choosing what Advanced Diagnostics dubbed the ‘Ride Out’ team -- “a group of essential employees who decide to stay at the facility throughout the hurricane to care for patients.”

    And for non-essential employees, Turner said to “ensure they are able to work remotely from safe environments. In addition to providing peace of mind, this allowed us to keep our back-end operations running as usual.”

    And lastly, Jenson recommended organizations put a post-storm plan into place to make sure the hospital is up and running as “soon as it’s safe to do so.”

    “Communication is key, especially in having a plan for after the storm,” said Jenson. “A lot of focus is spent on how to stay up and running and how to protect patients after the storm. But after the storm is where a lot of the hard work begins.”

    This includes patients with a lot of needs, and serving the community that will be in a tough spot after the storm.

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    Primary care physicians spend more than half of their workday typing data on a computer screen and completing other EHR tasks, according to new research from the University of Wisconsin and the American Medical Association.

    Researchers gleaned their findings from EHR event logs. Confirmed by direct observation data, they found that during a typical 11.4-hour workday, primary care physicians spent nearly six hours on data entry and other tasks with EHR systems. The study was published in the Annals of Family Medicine.

    [Also: Doctors loathe their EHRs, right? Not these physicians]

    “This study reveals what many primary care physicians already know – data entry tasks associated with EHR systems are significantly cutting into available time for physicians to engage with patients,” AMA President David O. Barbe, MD, a family physician from Mountain Grove, Missouri, said in a statement.

    Barbe blames poorly designed and poorly implemented EHRs for the growing sense among physicians that they are neglecting their patients as they try to keep up with an overload of type-and-click tasks.

    Doctor burnout rates are at more than 50 percent, according to Barbe.

    An overhaul of EHR systems is needed to address the lack of actionable data for patient care; convoluted workflows that take time away from patients; and long hours added to difficult clinical days just to complete quality reporting and documentation requirements.

    The AMA is calling for the implementation of eight priorities for improving EHR usability, calling for a reframing the design and configuration of EHR technology to emphasize the following priorities:

    • Enhance physicians' ability to provide high-quality patient care
    • Support team-based care
    • Promote care coordination
    • Offer product modularity and reconfigurability
    • Reduce cognitive workload
    • Promote data liquidity 
    • Facilitate digital and mobile patient engagement
    • Expedite user input into product design and post-implementation feedback

    The AMA said it recognizes that many of the recommendations can only be implemented in the long-term due to vendor product development life-cycles, limitations of current legacy systems and existing contracts, regulations and institutional policies.

    “However, there is a great sense of urgency to improve EHRs because every patient encounter and the physician’s ability to provide high-quality care is affected by the current state of usability,” AMA writes in its call for action.

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    Of the varied threats facing healthcare provider organizations today, both external and internal, what rises to the top? Some cybersecurity experts have solid opinions on that.

    When it comes to external threats, ransomware is the most urgent said Mike Fumai, COO at AppGuard, a cybersecurity software company.

    “The longer term and newer threat with ransomware is medical devices,” he said. “Already hackable, but no real economic model yet for adversaries to focus on. That can change quickly. For example, they can simply extend the ransomware model by denying medical device use until a ransom is paid. The complexity of the medical device supply chain, however, poses even more exotic ransom possibilities.”

    [Also: Old legacy devices pose greatest security risk, experts say]

    If a provider organization cannot treat patients because it doesn’t have access to medical equipment, records, billing processes, scheduling or vital third-party services, the impact is immediate, pervasive, urgent and even life-threatening – far worse than HIPAA fines and other typical data breach consequences.

    “Healthcare providers are not prepared for ransomware attacks,” Fumai said.

    So what should healthcare providers do to better prepare? Implement system back-ups and conduct realistic exercises to be sure they work is one tactic.

    [Also: Obama's cyber czar warns of 3 troubling security trends]

    “Continuously conduct realistic, simulated attacks on your employees and track them individually, and on your organization two to four times per year to seek and fix human weaknesses,” Fumai said. “Form at least one peer group within 30 days with signed letters of intent to learn how to better fight ransomware and to field-test and hype-test cyber products and services before deploying them.”

    When it comes to internal threats, access to patient records rises to the top, said George Brostoff, co-founder and CEO of SensibleVision, a cybersecurity technology company.

    “Twenty-seven hospital employees in New Jersey were suspended after they improperly looked at the files of actor George Clooney, who was being treated after a motorcycle accident,” Brostoff said. “All of them had access to the files from inside the system. External hacks get all the press, but the real security issues that affect hospitals every day come from inside the building.”

    When very private information is leaked, it is very embarrassing and damaging to a healthcare organization’s image and destroys the trust it has built with its patients. The specific data in patient records allows the source of the leaked information to be tied to the organization at fault.

    “Most important, these leaks violate federal HIPAA rules and other regulations, which can put accreditation at risk and also open up the risk of lawsuits,” Brostoff said.

    To combat problems associated with internal access to patient records, the first step is getting rid of passwords to protect any data, Brostoff said.

    “They just don’t work, and everyone acknowledges that – even the guy who came up with the ‘Change your password every month’ approach to security,” he said. “Following industry best practices such as secure authentication, encryption and proper access policies is the only way to protect data.”

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    Worcester, Massachusetts-based UMass Memorial Health Care, is preparing for a system-wide Epic go-live on October 1, part of a 10-year project that is expected to cost more than $700 million.

    “Anytime you spend $700 million on something at a not-for-profit, it raises a lot of eyebrows,” president and CEO Eric Dickson, MD, said.

    But, Dickson is used to raising eyebrows and is ready to own the decision. The first thing he did when he took the helm at UMass Memorial in 2013 was to bring the medical school and health system together for a strategic planning retreat.

    [Also: Epic is coming to UMass Memorial]

    It was then that the senior leaders in both organizations agreed that upgrading the IT system to be prepared for the future of healthcare was the top priority.

     “Now a lot of people talk about the Epic go-live, which is Oct. 1, just 17 days from now. But, this is not just about Epic. This is a complete redo of the monitors, so the monitors feed into the electronic health record so I don’t have to be sitting in front of the monitor.”

    Clinicians will be able to monitor patient status from anywhere.

    UMass is creating a single data repository, “a data lake that will allow us to do research to find better ways of taking care of patients,” Dickson said. “It’s about creating a platform for virtual visits so people don’t have to come in for everything.”

    The health system is also creating a patient portal, retraining staff and redoing data sets.

    “So often this gets labeled as the Epic project,” Dickson said.

    As he sees it, people forget that Epic is the software and UMass has also undertaken an upgrade of all its hardware and the network as well. Also, the staff skills have been upgraded at a significant cost, he said, and the workflows have been changed.

    The Epic go-live is a big part of it, he said, but it’s not the whole project. He figures Epic accounts for about $200 million of the total $700 million, cost. The rest is infrastructure, training, hardware, network closets, better bandwidth and a Microsoft Office suite – all of which is needed to support having an integrated electronic health record, he said.

    Dickson has been through a go-live elsewhere, so he expects there will be problems – “a lot of little problems,” he said. “But, I don’t worry about that. We’ve got a great team that will deal with that.”

    He acknowledges that transitions are always risky, but UMass has procedures to manage whatever comes up, he said.  

    He knows once the system goes live to expect it will take some getting used to, notwithstanding the training.

    “Even though this will be a much better system than we have, Dickson said, “that doesn’t mean on Day 1 it will be easier to use. It’s going to take some time to get used to it.”

    If the Epic EHR, which replaces a patchwork of technology from several other vendors, increases hospital efficiency by just 2 percent each year over the next five years, Dickson figures it will have paid for itself.

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    Investigators at Brigham and Women's Hospital in Boston have found clinical data more reliable than claims statistics for measuring incidences of sepsis.

    The findings, published Wednesday in JAMA, question the use of claims data for sepsis surveillance and conclude clinical surveillance using EHR data provides more objective estimates of sepsis incidence and outcomes.

    “Sepsis, the syndrome of life-threatening organ dysfunction caused by infection, is a major cause of death, disability, and cost,” the researchers said.

    [Also: Intermountain, University of Utah Health embark on plan for advanced cancer screening tool]

    The researchers found many studies suggest the incidence of sepsis is increasing over time, while mortality rates are decreasing. However, reliably measuring sepsis incidence and trends is challenging, they say because clinical diagnoses of sepsis are often subjective. Also, claims data – the traditional method of surveillance – can be affected by changing diagnosis and coding practices over time.

    The Brigham and Women's Hospital research estimates the current U.S. burden of sepsis and trends using clinical data from electronic health record systems of a large number of diverse hospitals.

    The findings, published in JAMA, challenge the use of claims data for sepsis surveillance and suggest that clinical surveillance using electronic health record data provides more objective estimates of sepsis incidence and outcomes.

    The research team, led by Chanu Rhee, MD, a critical care and infectious disease physician at BWH, developed a new strategy to track sepsis incidence and outcomes using electronic clinical data instead of insurance claims.

    After reviewing EHR data from nearly 3 million patients admitted to 409 U.S. hospitals in 2014, researchers found sepsis was present in six percent of all hospitalizations and in more than one in three hospitalizations that ended in death.

    Using this data to gauge how many people were affected nationwide, they estimated there were approximately 1.7 million sepsis cases nationwide in 2014, and, of those, 270,000 died.

    The researchers also assessed whether sepsis incidence and outcomes have changed over time. In contrast to prior claims-based estimates, they found no significant changes between 2009 and 2014.

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    Epic Systems introduced its Share Everywhere feature, which enables patients to grant doctors and caregivers access to their data.

    Not to be confused with the EHR vendor’s Care Everywhere, which enables health information sharing between providers, Epic’s Share Everywhere gives patients more control over the data sharing process. 

    [Also: Epic adds Mayo Clinic educational health info to patient-facing apps]

    Here’s how it works. A patient already using Epic’s MyChart patient portal can tap into the Share Everywhere feature to generate a one-time access code that the patient would verbally tell the doctor, according to an Epic spokesperson. 

    The clinician, in turn, would take that code to a Share Everywhere website and verify it against the patient’s date of birth. 

    “In addition to having a view of the patient's record, the doctor would be able to enter a progress note regarding the visit, which would be sent back to the patient's home provider,” the spokesperson said.

    Because the patient determines exactly who gets that access, Epic said their privacy is protected. 

    John Halamka, MD, CIO of Beth Israel Deaconess Medical Center, which said this year that is merging with Epic customer Lahey Health, said Share Everywhere supports two types of interoperability that hospitals need.   

    “Interoperability needs to have two approaches: caregiver to caregiver, if that’s what the patient wants, caregiver to patient to caregiver, for those who want to be stewards of their own data,” Halamka said. 

    Share Everywhere will be available at no cost in the November update of Epic’s MyChart, the company said.  

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    The newest addition to Epic's App Orchard is PeraHealth, whose real-time predictive analytics tool will be integrated through API into the electronic health record platform.

    PeraHealth's clinical surveillance technology is based on the Rothman Index, which measures patient acuity with an assigned score, helping hospitals spot at-risk patients for earlier intervention. It's deployed at major health systems such as Yale New Haven, Houston Methodist, Children's Hospital of Philadelphia and Memorial Sloan Kettering Cancer Center,

    [Also: Epic unveils interoperability tool for patients]

    The PeraTrend tool shows clinicians a dashboard that indicates the patient's condition in real-time, allowing care providers to detect subtle but potentially life-threatening changes – at either a nursing unit level or across the hospital for real-time clinical surveillance.

    At Yale New Haven, 1,541-bed tertiary medical center, PeraHealth's technology, enabled by APIs from App Orchard, is available via Epic EHRs across the enterprise, including a customized patient list called MyList that lets clinicians see the conditions of their specific patients.

    "Having access to third party solutions, like PeraHealth, which smoothly integrate with our EHR platform allows our organization to truly get the most out of our EHR investment," says Lisa Stump, chief information officer at Yale New Haven Health and Yale School of Medicine. "Our team has been able to integrate key features from Epic into PeraTrend that enable a seamless workflow and help improve quality of care, ultimately increasing value for the patient."

    "Healthcare organizations are seeking to maximize the use of their EHR platforms, and look to do so in a way that is customized to their clinicians' needs," says Stephanie Alexander, CEO of PeraHealth. "With the compatibility available through the App Orchard, we can smoothly integrate with Epic platforms to improve workflow for care teams."

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    How can health systems deliver the right care, at the right cost, in the right setting, without overwhelming delivery and reimbursement systems with administrative burden?

    The shift from volume to value-based care requires the deft combination of value-based delivery (enabled through actionable intelligence and new care delivery models) and value-based payment (enabled through select provider networks and new reimbursement models).

    Providers and payers must operate across a transparent, administratively simple, shared ecosystem. This giant leap from today’s world might appear impossible; however, as providers take on greater accountability for cost, and share more risk with payers, there is a real urgency for change.

    The good news: the technological capabilities needed to affect change are available today. What’s missing: an effective bridge between the current volume-based systems, where communication between providers and payers happens after the care decision (with the limited exception of pre-authorization), and a value-based system, where rich data and enhanced intelligence are automatically shared in real-time to inform decision making.

    Such a bridge can be built by starting with the current, albeit flawed, pre-authorization model as a foundation, enhancing current core systems and investments rather than trying to completely rebuild healthcare. The result is a new form of utilization management (UM) that shifts the balance of interactions from post-care decision with claims to pre-care decisions.

    This can be done through multiple layers of seamless automation that use existing medical information systems (i.e., electronic health records (EHRs), care management portals, etc.) to minimize or even eliminate routine administrative tasks, and empower providers and payers to focus manual medical necessity and authorization review efforts only on cases that require their clinical expertise.

    This exception-based approach increases the value of review and authorization processes by adding evidence-based decision support to their roles. By driving communication around evidence-based practices and appropriate care at the point of decision, the industry starts to bring value-based care delivery and, ultimately, value-based payment together.

    Solving this practical challenge will foster genuine collaboration between payers and providers based on a shared priority to ensure that quality care for value is delivered, while significantly reducing their administrative burdens.

    The limits of traditional utilization management

    The shift to value-based care would seem so logical and promising that nearly all stakeholders would want to support it. The reality is that current payer-provider relationships, their technological systems, and their organizational infrastructures are only now becoming ready to accommodate the transition.

    In the new world of value, payers and providers should be able to collaborate effortlessly at the point of care. A patient entered into the system by the provider should automatically trigger the relevant data, processes and tools needed to deliver cost-effective, evidence-based quality care.

    Providers and payers should know the patient’s relevant care history, which approaches and treatments are supported by the evidence, and whether those are included in the patient’s insurance benefits package and provider network. The payment of care should be administered under the appropriate reimbursement model, and providers should have shared access to the data and actionable intelligence needed to deliver the right care in the right setting.

    This is decidedly not the case in the traditional volume-based healthcare system. Pre-authorization and admission review are limited and often flawed examples of opportunities for payers and providers to interact and determine the clinical and financial impacts of care.

    Under the current approach to UM, providers must seek approval from payers for care through a cumbersome, manual and often retrospective process.  This puts payers in the position of serving as guardians of cost, medical necessity, network utilization and reimbursement rules.

    Traditional utilization management also fails to deliver rich data on provider utilization patterns and network performance that can be shared between payer and provider. This hinders the development of improved policies, high performing networks and effective, targeted provider interventions.

    Not surprisingly, payers and providers view this relationship as adversarial and the traditional utilization management function as a burdensome but necessary evil, fraught with the potential for conflict.

    According to a study from the American Medical Association1

    • About 64 percent of physicians reported difficulty determining which tests, procedures and drugs require authorizations.
    • About 63 percent of physicians reported waiting several days for authorization responses on tests and procedures, while 13 percent waited more than a week.
    • Nearly all of physicians reported that eliminating authorization hassles was “very important” (78 percent) or “important” (17 percent).

    The percentage of medical claims reporting prior authorization increased on average by 2.3 percent from 2011 to 2013, with some payers doubling and tripling the number of care events that require authorization.5 Additional studies found each preauthorization costs payers and providers between $50 and $100, adding to the $74 billion annually2 in administrative costs to payers, and increasing the estimated $31 billion in annual administrative costs burdening providers (roughly $68,274 per physician).3

    While the complexity and uncertainty created by the shift from volume to value-based care is significant, the opportunities created by reform are promising. It is estimated, for example, that enhanced collaboration can lead to a significant reduction in the $800 billion lost to administrative inefficiencies, provider inefficiencies and error, medically unnecessary and duplicative care, unwarranted use, and overutilization and fraud and abuse.4

    Shifting to a collaborative exception-based model

    Although traditional utilization management tends to be universally disliked, if transformed into a new collaborative model, it could serve as a bridge to the future.

    Utilization management already drives the collection and aggregation of clinical and financial performance data, although it is generally not available for analyses until long afterward when claims and care management data has been retrieved and reported. That said, it is precisely this aggregation of clinical data that provides an opening for collaboration and for enhancing decision support in advance of care.

    While the administrative burden of conducting a manual review is high, it is possible to automate the authorization process by integrating it into both the payer’s and provider’s workflows. This would lead to a significant reduction of the manual work involved in following up on authorization requests as well as helping to eliminate redundant medical reviews.

    This process could be further streamlined by programmatically extracting data directly from the electronic health record (EHR) to automatically populate the medical review. Querying the clinical record directly in this way brings obvious advantages to the UM process, reducing the administrative work required for the medical review, and reducing human errors introduced when clinicians manually copy information between multiple systems.

    Significantly, from the payer’s perspective, automating this process increases the trustworthiness of the review because the clinical data came directly from the EHR—the source of truth—without human intervention. And when the automated process transfers the clinical values into the medical review, that additional transparency further enhances trust.

    In this scenario, immediate approval could be generated based on medical review results coupled with the payer’s business rules. Automated decisions could also take into account data on provider utilization patterns and network performance.

    The ability to configure options based on the utilization patterns of a provider or care event is important to developing a collaborative win-win relationship between a payer and its providers. The more the provider’s practices are in line with evidence and policy, the lower the administrative burden.

    Both the payer and provider can see this practice data—the provider can demonstrate proficiency, and the payer can monitor and incentivize provider participation without the burden of a manual discussion. In the process, the provider will know automatically if care events are covered, what the appropriate medical and network polices are, and whether they require a deep manual review or simply a notification as they are making their decisions and before the care is delivered.

    To drive optimal provider adoption, this must be done across care events—diagnostics, procedures, specialty drugs, DME, etc.—and across their various payers, bringing a familiar, common workflow to the user, which is much more attractive than having to go to multiple systems for multiple payers.

    Optimizing utilization processes with analytics

    How does a payer continue to manage authorizations that are approved the majority of the time, without intervening in the care delivery process excessively? The data generated by automation must be gathered in a cloud-based shared ecosystem, measured and smartly managed by exception.

    In this way, the payer intervenes only to the degree necessary. If the provider is delivering appropriate, evidence-based care, then the burden of scrutiny should be minimized and it should be easier for the provider to deliver and be reimbursed for care. That is the formula for a collaborative payer-provider relationship and one needed for value-based care.

    To understand when interventions can be minimized, payers must measure and manage utilization patterns, while refining policies and processes.

    1. Measure Measuring utilization data requires examining it in aggregate as part of an overall trend, rather than in terms of individual authorizations. Doing so makes apparent which requests are being automatically approved and which are automatically reviewed or canceled, and how frequently such interventions happen. This can be done based on the plan, product, provider, patient or care event.
    2. Manage Drilling down, payers can compare utilization patterns of different networks and providers, and observe variations in care events and procedures. Accordingly, the health plan can identify outliers where requests are higher volume compared to the peer-set norm, in or out of network, or not in line with evidence-based approaches. In addition, it can also see when requests are routine and do not warrant additional scrutiny that would waste administrative resources. Based on this data analysis, the health plan can build a nuanced exception-based approach by refining and optimizing its rules of authorization to facilitate the approval of requests that are aligned with quality and cost objectives while triggering notification in the system to scrutinize requests that are outside of their set parameters.
    3. Refine Once a system is in place to automate routine requests and signal alerts about outliers, the health plan and the provider can work together to understand the root causes of the outliers and intervene as appropriate. Ultimately, this collaboration can result in improved performance for the system from both administrative and medical cost perspectives that benefit the provider and the payer alike. This can also serve as key performance data for value-based relationships between them.

    The more providers can align their care practices with the benefits and policies of the payer, the more providers will avoid the administrative burden of utilization management and be better able to demonstrate their value to a payer’s narrow network.

    Performance-driven collaboration

    In a value-based system, we are striving toward collaboration. How can exception-based utilization management be implemented, and what are the benefits of this model for both parties?

    In this system, payers and providers communicate about care delivery in near real-time and learn to develop a more nuanced understanding of utilization patterns and variations in care. Over time, payer rules and actionable content can be infused into the many points of decision that are being made by the provider. This will help determine the appropriateness of medical care while also reducing administrative burdens. Most significantly, it creates a traversable pathway to a value-based care system.

    This approach engages providers and payers with a common language. They are using a shared technology to measure, manage and refine quality care delivery in line with coverage policy. It reduces barriers internally, and between payers and providers, so that the various functions can communicate across traditional silos. Eventually, this also opens the door to integrate shared rules into the provider’s workflow.

    This is an essential bridge from volume to value. When utilization patterns and the benefits of improved performance are shared openly, the provider can organize its care delivery to drive value, and the health plan can incent or support such efforts by paying for value. Over time, payers will direct more care to the best performing providers, as defined by their ability to meet quality and cost goals in accordance with evidence. The best providers will work to increasingly align their practices to meet the payer’s definition of value.

    Making the vision real

    A transformative system is well within reach. It starts with the technology tools and platforms being developed today, and the collaborative ecosystem forming among the network of payers, providers and vendors across the healthcare space. 

    By fully automating the authorization process, redundancy—where both payers and providers perform the same medical reviews—can be eliminated, and authorizations can be provided without needing to manually handle the request. This helps reduce administrative costs, speed authorizations, and helps ensure appropriate care.

    Exception-based UM is now a reality, and the elimination of the adversarial relationship heralds better days ahead for payers, providers and patients.

    About the Author:

    Nilo Mehrabian:Vice President, Product Management, Decision Support, Change Healthcare

    Nilo Mehrabianhas more than 25 years of experience in the healthcare market, serving the last 20 years in healthcare IT. She is responsible for the Decision Support products at Change Healthcare.


     1American Medical Association, AMA Survey of Physicians on Preauthorization Requirements (May 2010)

    2Medical Economics, Curing the prior authorization headache (October, 2013)

    3McKinsey & Company, Preauthorization sizing, McKesson report (2008)

    4Health Affairs, What Does it Cost Physician Practices to Interact with Health Plans? (July/August 2009)

    5Thomson Reuters report, (October, 2009)

    6American Hospital Association, Study: 75% of hospitals have at least a basic EHR (November, 2015)

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    The variety of potential blockchain deployments in healthcare is getting wider. When ONC put forth its call for white papers in its blockchain challenge, for instance, it received more than 70 submissions earlier this year, exploring everything from medication reconciliation to alternative payment models.

    And as the distributed ledger tool gains ground in other industries, the thinking about how it can help healthcare's many challenges has only gotten more creative.

    At the HIMSS Healthcare Security Forum in Boston last week, Maria Palombini, director of emerging communities and initiatives development at the IEEE Standards Association, framed some expectations for the much-hyped technology.

    [Also: Blockchain eyed for potential use cases in revenue cycle]

    For all the excited chatter surrounding it, blockchain is still an emerging technology and "failures and resets are to be expected," said. "There are still quite a few challenges that need to be resolved in order to make adoption happen."

    Blockchain "is not meant to wipe out existing legacy systems," she added, but if deployed wisely, the technology could underpin an array of new innovations that could help reduce costs, enable efficiency, protect privacy and spur interoperability and much more.

    The potentials for blockchain and blockchain-like tools – decentralized, transparent, verifiable, secure and private – are everywhere, said Palombini.

    By ensuring that any changes in data are made by the participants in a given transaction, she said, the technology's use cases run the gamut from IoT medical device security to supply chain integrity to claims processing and clinical trials efficiency. 

    "Blockchain is booming in clinical trials right now; it is a big favorite of the pharmaceutical sector,” she said.

    A 'utopian' answer to EHR challenges?

    But one place where Palombini sees especially intriguing promise is electronic health records.

    "When you think about all the data (in and EHR), what do you put in it? Genomic data, hospital records, immunization records, lab results – there's an enormous amount of data," she said. "The question then becomes, ‘Do I have to do this over and over every time I go to the hospital or I go to my doctor?’"

    Palombini said a public blockchain could be just the thing to enable more seamless – but still secure – sharing of health data, all within the patient's discretion and control.

    "Everything you have in your health record gets put into the blockchain, and then the patient is managing their health record," she said. "I have my health record, and then I go to my doctor I give him a token to access my records.

    "How many times have you gone to the doctor and they ask, 'What medicine are you taking? What is your wearable telling you?'" she added. "Why are you spending 15 minutes of your time with your doctor re-reciting something you think is written down in his chart from the last time you were there? Especially if you go to a new doctor, you want him to be able to have your health record."

    She remembered a recent visit with her father-in-law – an older gentleman who doesn't speak English – to the hospital emergency room.

    "We check into the emergency room, and they ask us why we're here, they start asking him for all of this information: 'What kind of procedure did you have? What medicine are you taking? What's your health history?'

    Then, later, the ER doctor started "asking us all of the same questions again," she said. "I thought, 'Didn't you just read all of the information we just filled out at the registrar?'"

    After an evaluation, Palombini's father-in-law was eventually told he had to stay overnight.

    "So we head upstairs to the next floor, where we get asked the same questions once again," she said. "I'm sitting there, thinking out loud, and I say, 'Blockchain would have solved this problem.'"

    In each step of that phase of the patient encounter, "what are we doing? We're verifying data,” she said. “We're making sure that the person before us wrote it down accurately. We're asked again to make it double secure."

    Of course, that's usually based on hospitals' policies and protocols. But the root cause for all that double- and triple-checking is that "we're not so confident about the technology and how we're taking down information," she said.

    In a recent blog post, Elizabeth G. Litten, partner and HIPAA privacy & security officer at Fox Rothschild, said that "using blockchain technology to reconfigure EHRs makes sense."

    Indeed it's ironic, she said, that a "design flaw" in the original HIPAA law – encouraging electronic health transactions that enable portability for patients' who move among various sites of care, while treating privacy and security as an "afterthought" – could potentially be addressed by the same technology underpinning the cryptocurrency, bitcoin, so "favored by ransomware hackers."

    Litten pointed to another post, by Ritesh Gandotra, director of global outsourcing for Xerox, who wrote that, "EHRs were never really designed to manage multi-institutional and lifetime medical records; in fact, patients tend to leave media data scattered across various medical institutes … This transition of data often leads to the loss of patient data."

    Blockchain, he said, "can be used link discrete patient records (or data “blocks”) contained in disparate EHRs into "an append-only, immutable, timestamped chain of content."

    At HIMSS17 in Orlando this past spring, Tamara StClaire, previous chief innovation officer at Conduent Health, spoke at a blockchain symposium sponsored by IEEE and the Personal Connected Health Alliance.

    She explained that new approach to patient records: "One way to think about it is the fact that not your identification but your data is hashed to the ledger," she said. "It's an address you're looking for. And there can be multiple addresses. And a patient can hold multiple keys to those addresses in their electronic wallet."

    There would be a whole lot of other questions that would accompany such a fundamental change of "transferring ownership of data to patients," said StClair.

    "All of a sudden we have a new paradigm about the way we think of privacy. We may need to set default levels for the people who are uncomfortable with the magnitude of that responsibility. There's a lot we need to dig into, and that conversation needs to start."

    But blockchain could help lead to a "Holy Grail," she said. A longitudinal view of a patient's health history that incorporates information drawn from hospital stays, outpatient visits, wearable device data and more.

    Palombini used similar language when she described a blockchain-built, mobile EHR.

    "This is utopia," she said. "It's going to a while for us to get there. But this is why we're so motivated in the application of blockchain. And I say 'challenges,' not 'roadblocks.' Because they can be overcome."

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    Mayo Clinic and EHR vendor Epic Systems have added Mayo’s symptom checker functionality into Epic’s MyChart portal. 

    The new arrangement means that patients can use the symptom checker, previously available on Mayo’s website, to assess common ailments, such as dizziness, swelling, anxiety, migraine, cold or flu. 

    Mayo’s symptom checker is driven by algorithms based on data entered by users. It runs 36 algorithms that cover more than 300 common symptoms.

    [Also: Epic unveils interoperability tool for patients]

    “Care guidance, based on the user’s selection of symptoms and responses to relevant questions, includes more information about possible causes tied to the symptoms, and, in most cases, provides recommendations on home care in non-emergent situations,” said Sandhya Pruthi, MD, a physician in the Division of General Internal Medicine and associate medical director at Mayo Clinic Global Business Solutions.

    Mayo Clinic is offering Ask Mayo Clinic online as an option to both patients and healthcare providers who use Epic EHRs. The idea is to help other healthcare providers share the symptom assessment tool with patients.

    [Also: Epic adds Mayo Clinic educational health info to patient-facing apps]

    Mayo Clinic healthcare providers and nurse experts provide all symptom assessment content, Mayo Clinic noted, adding that content is regularly reviewed and edited to ensure accuracy.

    To access Ask Mayo Clinic online, patients at participating health systems can look for the “Ask Mayo Clinic” navigation option within the MyChart portal.

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    Advisory Board Senior Vice President Rob Barras discusses the need for providers to start locally to spark interoperability while recognizing there’s no one-size-fits-all approach.

    Interoperability is one of the most difficult challenges with electronic health record optimization: The ability to share clinical data across health systems and respective EHRs. Sometimes it takes a personal experience to drive home the meaning of interoperability, not only to the healthcare professionals who regularly interface with the EHR, but the patients.

    When EHR interoperability hits home

    For those that read my last post, you know that I lost my 40-year-old brother to a heart attack in 2015.  I had a physical about two months after my brother died, but due to my family history of heart disease, I also made a long-overdue appointment to see a cardiologist. Both my primary care physician and cardiologist work within the same system and use the same ‘integrated’ EHR. And yet the scheduler for the cardiologist requested I fax my EKG and history, including labs, to the office prior to my appointment.

    Needless to say, we know interoperability will doubtlessly improve patient care and experience. But it can often feel like a mammoth, unachievable task. Some staff are accustomed to jumping through hoops to access data, but it doesn’t have to be that way. The secret is to approach interoperability on a smaller scale and address the changes you can make more locally to move the needle forward. Interoperability is a spectrum, and the right answer for one health system may not be the same for another. 

    Small steps toward interoperability

    Every health system executive has interoperability on their priority list these days, with exciting strides in personalized medicine, the day-to-day demands of care management and reducing unwarranted care variation.

    So where should you start?

    First, as leaders in this industry, we need to recognize interoperability isn’t just a technology problem. Opening up access to clinical data across different care settings must be a strategic priority that starts with an honest assessment of a health system’s technical capabilities against the imperative to deliver better patient care. Health systems can’t afford to be left behind here, but can’t do it alone. In an industry rife with mergers and acquisitions, health systems should work from the inside out. While that might seem obvious, many systems struggle to make sure internal stakeholders have access to data on the system in some way or another. 

    Second, there’s more than one right technique to achieve some level of interoperability. While a truly integrated EHR is the ultimate goal, it’s typically more costly, time-intensive and organizationally disruptive than other options. There is a myriad of interface engines/brokers, health information exchange tools, APIs and custom-built options that can be implemented much more quickly and provide real value, at the point-of-care, now.

    Most health system executives assume that to achieve interoperability, they need to implement or migrate every provider in their system onto the same EHR. And often this course of action is advised. However, I’ve seen clients use some innovative methods to tackle interoperability.

    One of my favorite examples is a large health system in the northeast that explored different methods to standardize access to data without moving to the same EHR platform.

    As the health system acquired new physician practices, it faced limitations that made an integrated EHR financially and operationally prohibitive. After exploring its options, the health system opted to create an HIE, a safe way to send and standardize patient records between EHRs. While the data are not truly in one single place, HIEs give clinicians access to data across separate systems within a couple clicks.

    Achieving interoperability will be a long journey that will only grow in importance as healthcare shifts from a volume to value mindset. When possible, health systems should move to an enterprise EHR architecture and go beyond minimally meeting regulations. There’s no such thing as true, complete interoperability: There will always be a new source of data with a different set of access issues. But in the interim, work with community partners to craft solutions to affect patient care now.

    Rob Barras is Senior Vice President of Consulting at Advisory Board.

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    Mayo Clinic and National Decision Support Company announced on Tuesday a new offering that enables physicians to access clinical guidance about laboratory tests at the point of care.

    The new offering comes as hospitals, EHR vendors, the federal government and others in the healthcare industry are looking to incorporate more actionable clinical decisions support capabilities into electronic health records.

    Earlier this month, for instance, the Clinical Decision Support Coalition posted voluntary guideline for designing such decision making tools in response to provisions in the 21st Century Cures Act that moves some CDS products outside the U.S. Food and Drug Administration’s regulatory scope.

    [Also: HIMSS Big Data and Healthcare Analytics Forum to focus on the information revolution]

    The new CareSelect Lab software, for its part, is a clinical decision support tool that the organizations said aggregates Mayo’s medical knowledge about health conditions and is integrated into electronic health record platforms to essentially deliver best practices through NDSC’s CareSelect platform.

    NDSC CEO Michael Mardini said the combination means that customers can access more 1,500 care models that Mayo maintains.

    Physicians can tap into CareLab for guidance on laboratory, pathology and genetic testing, as well as interact directly with the guidelines from their EHR workflow to access information about appropriate tests to order.

    And at the enterprise level, hospitals using CareSelect and CareLab can also view analytics benchmark to compare doctors ordering patterns, better understand overall test trends and pinpoint gaps in care, Mayo and NDSC said.

    Mayo’s Department of Laboratory Medicine and Pathology chair William Morice, MD, said the tools can help physicians reduce common mistakes, whether those doctors are on staff at Mayo or access its lab tests.

    “We must extend to them the same decision guidance that we avail to our own physicians and scientists,” Morice said. “And we must do so in a way that integrates with their current workflows and systems.”

    Although Mayo did not state how much CareLab or the CareSelect platform cost, it did disclose a financial interest in the product and said it will allocate the revenue it earns from the product for its not-for-profit education, patient care and research work.

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    UI Health, an academic medical center, which is associated with the University of Illinois in Chicago, will plunk down $101 million for an Epic System EHR.

    The cost includes the preparatory work UI will have to undertake prior to installing the EHR.

    The cost associated with the Epic rollout is $62 million over seven years. It includes software, remote hosting, implementation, licensing and other fees.

    [Also: Epic notches a first with Canadian EHR install]

    Once the contract with Epic is finalized, the new system will take about 21 months to roll out. ‘Go Live’ is expected to occur in the fall of 2019, Michael Zenn, chief financial officer of UI Health, told Healthcare IT News.

    A 17-member assessment committee helped develop a process and set technology criteria. The team also oversaw development of the RFP – request for proposal – and an evaluation of the responses.

    [Also: Epic rollout at New York hospital backed by $5.7 million state grant]

    There were also technology demonstrations from several vendors.

    “For Epic, we had 460 participants in our demo. And, we received back 745 evaluations,” Zenn said. “We had a large number of people looking into the process.”

    Once the Epic technology goes live, hospital administrators say, it will replace the disparate technologies in place today. They include pieces of Epic, Cerner, Allscripts, McKesson and Midas, which measures quality of care. Much of the technology dated back to the 1990s.

    “Many of our current systems were being sunset,” Zenn said. “We were being told by vendors they would no longer support them.”

    “We’ve had a large number of disparate systems – in all our departments that we acquired over time that don’t work all that well together,” he added. “We were looking for the ability of vendors who could in an integrated way through a more singular system accomplish our information needs.”

    As Zenn sees it, the upgrade is a necessity of the business.

    “It’s also a necessity for clinical delivery; communication with our patients, it’s a necessity for all the complex billing issues that we have to deal with.” he said. “It’s our ability to provide care, it’s our ability to interact with our patients about their care, their experience here. It’s about all of those.”

    UI Health includes a 495-bed tertiary care hospital, 22 outpatient clinics, and 13 Mile Square Health Center facilities, which are Federally Qualified Health Centers. It also includes the seven UIC health science colleges: the College of Applied Health Sciences; the College of Dentistry; the School of Public Health; the Jane Addams College of Social Work; and the Colleges of Medicine, Pharmacy, and Nursing, including regional campuses in Peoria, Quad Cities.

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    Lahey Health has achieved Stage 7 for both the Electronic Medical Record Adoption Model and the Outpatient-EMRAM model.

    HIMSS Analytics pointed to Lahey’s major strides in its use of technology to streamline patient care in a consistent and more efficient manner.

    Lahey Health joins only 5 percent of U.S. hospitals that have reached this highest level on the scale. Lahey Health is one of fewer than 40 U.S. hospitals and health systems  – and the only hospital or health system in Massachusetts –  to have earned the distinction for both acute and ambulatory care.

    [Also: 7 tips for EMR success from Stage 7 hospitals]

    Lahey Health put its EHR and related technologies to work on improving overall prescribing practices and the identification and management of opiate-dependent patients. Interventions included: documentation tools and workflows for opiate therapy consent and contracts, enhancing patient education and outreach processes and building reports to identify chronic opiate therapy patients.

    The Lahey Health team also used data from these reports to drive patient outreach and engage patients in reducing dependency through education, opiate agreement contracts and referrals for treatment.

    “With Lahey Health’s thorough deployment of electronic medical records, they have developed a comprehensive care environment,” John Hoyt, Stage 7 lead at HIMSS Analytics, said in a statement. “Their uniformity of system use is a testament to their enterprise commitment to using their EMR to drive improvements in care quality and efficiency, equally on the inpatient and outpatient basis.”

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    Billed as a "digital health studio," the newly-launched Doctella aims to help healthcare organizations develop patient-facing apps quickly, easily and inexpensively.

    Doctella CEO Amer Haider – who co-founded Doctella with his brother, Brigham & Women's Hospital surgeon and public health researcher Adil Haider, MD, and Peter Pronovost, MD, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine – says the future of healthcare is "apps and sensors."

    [Also: Boston Children's, Duke create new Apple CareKit app]

    On both the provider and payer side, healthcare professionals "both want to reach patients outside the clinical setting," said Haider. "We have a very strong belief that we can improve the quality of healthcare and manage costs with digital health intervention."

    The challenge, he said, is that "there's no easy way to collect data and to intervene: to say, 'Your heart rate is too high for the last couple days, we need to make sure you're doing OK.' There's no simple way to do it."

    The usual strategy is for nurses make phone calls to check in on patients, of course. In more demanding cases, staff from home health agencies visit the patient in person. "It's expensive and inefficient," said Haider.

    Customized apps can help "tell patients what they need to know at the right time," he said. There's been a lot of momentum on that front in recent years, whether it's Apple's CareKit, Google Fit, Samsung Gear or Qualcomm's work optimizing the cloud for for medical grade sensors, said Haider.

    "Hundreds of companies are building sensors for data collection. But how do doctors and payers make these apps? For most apps, it's going to cost $500,000 to $700,000 and take 10 to 12 software developers over many months.

    "If I have a clinic of 5,000 patients, it's just not feasible for me to spend that money to make an app," he added. "I just won't recoup the basic cost."

    Add to that the fact that "every hospital has different care plans. The clinics have slightly different care plans," said Haider. "And the population, with multiple co-morbidities or different treatment requirements need different apps. There's a huge need for personalization and customization."

    Hospitals or physician practices create an account on the Doctella website and can and design their own personalized and branded care programs using hundreds of preloaded clinical templates, across an array of specialties, which were developed by clinicians at Johns Hopkins and elsewhere, said Haider. They can also hire Doctella digital health experts to help them build the apps.

    Providers can invited patients to see their specific care programs via email, SMS or through their electronic health record.

    And using the company's integrated analytics dashboard, clinicians and staff can track patients' progress with the care plans via the patient's own feedback or mobile device sensors. Doctella makes it easy for physicians to to track reported outcomes, vital signs, exercise routines, medication adherence and more.

    Doctella's care programs have their roots in the checklists first developed by Provenost and colleagues at Johns Hopkins.

    "Over a decade ago, my colleagues and I at John Hopkins created a simple checklist that defined actionable tasks for doctors and nurses that decreased  the rate of deadly infections in the United States and led to the adoption of checklists as a standard of care," said Pronovost in a statement. "Doctella employs the implementation science that is behind checklists, and has worked with patients, caregivers, doctors and nurses, to create CarePrograms, which is easily customizable for providers and patients."

    Several physicians – dermatologists, otolaryngologists, surgeons – have already used Doctella to develop their own customized care programs.

    "Currently, verbal or paper instructions, a quick call from the doctor or a brief visit are considered state of the art methods for managing patients, outside a hospital or after they leave a clinic," said Adil Haider in a statement. "It is estimated that providers and health plans are wasting over $2.5B on these antiquated modes of partnering with patients. They desperately need a simple, low- cost way to create modern digital health interventions. These interventions can  guide patients and families outside of the hospital, follow them, and track outcomes based on device data input and patient reported outcomes."

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    Epic System’s Haiku app for iPhones is providing Doximity members one-touch dialing of patients through Epic’s mobile EHR.

    The integration between Doximity Dialer and Haiku also makes it possible for doctors to access patient records and communicate with patients from their mobile phones without exposing their personal phone number. 

    With Haiku, physicians can tap the contact information in a patient’s chart, which instantly opens the Doximity Dialer app to initiate the patient call.

    "Haiku provides authorized clinical users of Epic's EHR with secure access to clinic schedules, hospital patient lists, health summaries, test results and notes. The app supports dictation and access to “In Basket,” a secure messaging system. Haiku works on both the iPhone and iPod touch," according to the app's description on the AppStore.

    [Also: Wait! What? Amazon and Apple eye building EHRs]

    “Our goal is to connect physicians to make them more productive and successful,” Jeff Tangney, founder and CEO of Doximity, said in a statement. As Tangney sees it, the combination of Haiku and Dialer can make doctor-patient communication easier, and more efficient.

    Marlene May Millen, MD, chief medical information officer, ambulatory care, at UC San Diego Health, sees the integration as a way to save physicians time and perhaps make it easier to communicate with patients.

    The latest version of Epic’s Haiku mobile app has integrated Doximity Dialer, and any verified physician can download Doximity Dialer from the iTunes Store or Google Play. 

    Epic and Apple tested the Haiku app back in 2009 at Stanford Hospital & Clinics in Palo Alto, California.

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    When Allscripts acquired McKesson's Enterprise Information Solutions for $185 million this summer, it promised to maintain McKesson's Paragon EHR for smaller hospital clients. But a new report from KLAS argues that the company has a limited window to improve the product for those customers.

    The acquisition appears to have brought some momentary clarity to plans for the EHR, whose future had been clouded by uncertainty, said KLAS, which spoke to more than three dozen Paragon customers about the deal.

    Most hospitals say they'll be sticking with the plans they had in place before the acquisition, according to the report – whether that means continuing to use Paragon, replacing it or taking a wait-and-see approach to learn more about Allscripts' plans for the system.

    [Also: What's next for Allscripts-McKesson? Innovation and interoperability will be key]

    But about one in four customers said the deal is causing them to rethink: Some had planned to replace the system but now might stick around; others had been planning to stay with Paragon but now might replace it, they said.

    Of the first group, they're encouraged by the fact that, unlike McKesson, Allscripts is purely focused on health IT and says it's committed to investing the necessary resources to improve Paragon.

    But among the other cohort, they either "have had poor experiences with Allscripts in the past or fear that Allscripts is repeating McKesson’s mistake of trying to develop two EMR platforms."

    Whatever their near-term plans, the general consensus among the customers interviews is that if Allscripts wants to maintain Paragon hospitals, "they are going to have to move quickly to provide not just a strategy but actual improvements to Paragon’s functionality and support," said KLAS researchers.

    Paragon customers have long been disappointed by McKesson's attention to the EHR system, according to the report.

    The good news for Allscripts is that 29 percent of the Paragon hospitals interviewed by KLAS said they're confident that the new owner will work to develop and improve the system.

    "They believe Allscripts is looking to fill a gap, and they see the acquisition’s lower price point as a signal that Allscripts plans to put additional R&D resources into Paragon."

    But just as many say they have doubts, according to the report. "They feel developing Sunrise Clinical Manager and Paragon will divide Allscripts’ focus, and they view the lower purchase price as evidence that Allscripts doesn’t think Paragon is salvageable."

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    The Office of the National Coordinator for Health IT on Thursday revealed two changes to its certification criteria that officials said are designed to reduce the burden on industry and make the meaningful use program more efficient.

    The first is making more than half of test procedures self-declarable and the second is more discretion around randomized surveillance of certified health IT products.

    [Also: 4 former national coordinators, a CIO and a CEO weigh in on how to fix meaningful use]

    Elise Anthony, director of policy at ONC, and Steven Posnack, director of ONC’s Office of Standards and Technology, wrote on the Health IT Buzz blog that 30 of the 55 criteria were intended to support CMS Quality Payment Program and those are now self-declaration only.

    “This means that health IT developers will self-declare their product's conformance to these criteria without having to spend valuable time testing with an ONC-Authorized Testing Laboratory,” Anthony and Posnack added. “The test procedures for health IT products now designated as ‘self-declaration’ are for functionality-based certification criteria.”

    The second change ONC made on Thursday relates to randomized surveillance of ONC-Authorized Certification Bodies. The ACBs are required to conduct randomized surveillance for at least two percent of the health IT products they certify.

    [Also: Digital divide widening in hospital EHR deployments, report says]

    “ONC will not, until further notice, audit ONC-ACBs for compliance with randomized surveillance requirements or otherwise take administrative or other action to enforce such requirements against ONC-ACBs,” Anthony and Posnack wrote. “This exercise of enforcement discretion will permit ONC-ACBs to prioritize complaint-driven, or reactive, surveillance and allow them to devote their resources to certifying health IT to the 2015 Edition.”  

    ONC said that these changes are intended to ease the burden on health IT developers and certification bodies so they can focus more on interoperability.

    “This change enables ONC-ATLs and health IT developers to devote more of their resources to the remaining interoperability-oriented criteria, aligning with the tenets of the 21st Century Cures Act,” Anthony and Posnack wrote.  

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