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Articles on this Page
- 10/04/17--07:28: _My #IHeartHIT story...
- 10/04/17--08:27: _All-Flash Storage i...
- 10/04/17--09:15: _Canadian Cerner ins...
- 10/04/17--12:36: _CIO shares keys to ...
- 10/05/17--08:35: _My #IHeartHIT story...
- 10/05/17--09:45: _How Mount Sinai is ...
- 10/05/17--12:25: _My #IHeartHIT story...
- 10/06/17--05:51: _KLAS gives athenahe...
- 10/06/17--07:32: _Epic CEO Judy Faulk...
- 10/06/17--12:05: _New tech from eClin...
- 10/09/17--06:21: _Madigan Army Medica...
- 10/09/17--08:06: _OurHealth taps athe...
- 10/09/17--10:12: _EHR satisfaction su...
- 10/10/17--06:50: _EHR vendor drchrono...
- 10/10/17--07:46: _EHRs are holding tr...
- 10/10/17--09:25: _eClinicalWorks sign...
- 10/10/17--13:53: _4 Keys to Patient P...
- 10/11/17--08:11: _HIMSS issues intero...
- 10/11/17--09:29: _Meet the health IT ...
- 10/11/17--10:47: _As vendors target o...
- 10/04/17--07:28: My #IHeartHIT story: A personal wish for EHRs
- 10/04/17--12:36: CIO shares keys to a successful telehealth program
- 10/05/17--08:35: My #IHeartHIT story: Have patient data, won't travel
- A study demonstrating successful application of gene therapy to improve heart function in non-ischemic heart failure, reversing cardiac damage from congestive heart failure in a large animal model.
- Discovery of a predictive model for inflammatory bowel disease, published in Nature Genetics.
- Using machine learning, researchers identified unique insights in the way different opioid drugs activate the receptors and specific signaling pathways in the brain.
- 10/06/17--07:32: Epic CEO Judy Faulkner is standing behind switch from EHRs to 'CHRs'
- 10/10/17--06:50: EHR vendor drchrono says task management app will improve workflows
- 10/10/17--09:25: eClinicalWorks signs on with OpenNotes
- 10/10/17--13:53: 4 Keys to Patient Portal Engagement
- 10/11/17--09:29: Meet the health IT vendors working to end the opioid crisis
“But what about the lump in my armpit?” I asked, after just learning that my tenth annual mammogram was normal. “What lump?” asked the technician. “There is no lump visible on the mammogram.”
The radiologist assured me that even with an exam using ultrasound, the lump did not look suspicious. And that I probably needed to see a dermatologist. A biopsy was performed as a matter of precaution.
[Also: Read more #IHeartHITstories here]
A few weeks later the biopsy results came back and I learned that I did in fact, have breast cancer. According to risk assessment metrics, I have a less than 1-percent chance of ever being diagnosed with breast cancer. I have no family history of breast cancer, I do not carry the genes associated with breast cancer, and I have never had an abnormal mammogram. I did feel lumps but was always reassured that they were nothing.
I can honestly say I could not have ever endured cancer treatment without the support of my family, my faith, my oncologists and my community. There are dozens of residents who made meals for our family, ran errands, provided rides to treatment, and took my kids for play dates. I greatly appreciate all of the help that I received, and in return hope to be able to help others in some way.
Three surgeries, 42 radiation therapy treatments and four years of oral chemotherapy have provided me with six years of survivorship. However, in those years of carrying my disparate medical records from place to place, I had hoped for better integration. Yesterday, the radiologist still could not access my last six years' worth of images for comparison despite having all of my care encapsulated in one integrated delivery system.
We have been on Epic for a few years now and there is still a lot of work to be done before I will not need to update my care team members individually on my post survivorship care plan progress.
– Laura Manning Hill is the senior IT project manager at Dana Farber Cancer Institute.
This National Health IT Week, HIMSS is giving the industry a platform to share stories about how health IT is progressing. We are at a critical point on the path to healthcare transformation in the U.S. and policymakers want to know if we are making progress. Share your story and help impact policymakers.
British Columbia Health Minister Adrian Dix launched a second investigation into the Cerner electronic health record system of Island Health (Vancouver Island Health Authority) on Sept. 20 -- a result of a rollout that has caused severe turmoil between the health system and the providers who don’t want to use it.
The $174 million system was launched in March 2016 at the Nanaimo Regional General Hospital, Dufferin Place Residential Care Centre in Nanaimo and Oceanside Health Centre in Parksville.
Not long after the rollout, British Columbia Provincial Patient Safety and Quality Officer Doug Cochrane launched an investigation into the EHR to address the many complaints from providers.
What he found were critical functional deficiencies in the EHR: any user could inadvertently order unsafe medication doses, multiple orders of high-risk meds would remain active, the EHR extensively used small font sizes, drop-down menus had long lists that were tough to read, and the display was dense and difficult to read and navigate.
Further, end users were reporting issues with system responsiveness, log-in problems when changing computers, unexplained screen freezes, connectivity problems with the barcode readers and the PharmaNet integration wasn’t effective and added to the burden of medication reconciliation.
To its credit, IHealth said it addressed many of the issues. However, problems are still ongoing. In fact, use of the CPOE system was suspended in Feb. 2017.
Officials planned more EHR rollouts to the rest of IHealth facilities this year. But physicians and clinicians have repeatedly complained about the system’s dangerous dosage errors, system functionality and the amount of time spent on a laborious platform.
In fact, some providers have all-out refused to use the new EHR and have reverted to handwritten orders. A move, which first had IHealth officials asking other physicians to enter the handwritten orders into the system, according to Canada’s Times Columnist.
However, providers are now being penalized for not using a system they say is unsafe.
The EHR was “introduced as a wholesale change” in March 2016, said President of the Nanaimo Medical Staff Association David Forrest, MD. And he admits before the planned implementation, he knew nothing about EHRs.
“It’s archaic that we were still writing charts and orders in the era of iPhones,” said Forrest. “It didn’t make sense that we weren’t leveraging technology.”
However, while most physicians were ready for the change, Forrest claimed that the planned rollout was rushed -- the initial rollout was slated for August 2015 and was pushed back. And those in charge of the project felt pressured to get the EHR installed before the fiscal year in March.
But in private discussions, Forrest heard many express concerns prior to the rollout that it simply wasn’t ready. In fact, pharmacists, in particular, were vocal about the readiness of IHealth, as “computer order processes hadn’t been prepared properly.”
“But they forged ahead with it anyway,” said Forrest. And to make matters worse, “the launch itself was ill-timed.”
“It launched on a Saturday, during spring break, which means we were understaffed due to employees on holiday,” he said. “It was the worst possible time to launch -- and it was pointed out beforehand.”
As seen with successful installs -- for example, Penn Medicine, WellSpan and Vanderbilt -- training physicians before a new EHR is crucial. By allowing providers to get into the system and play with the tools, they can get a sense of what they can expect during routine care and how to mitigate potential errors.
However, as the rollout was rushed, Nanaimo providers were unable to do so.
“There was little opportunity for physicians and allied health professionals to receive good training with this,” said Forrest. “It was a mess.”
In fact, Forrest said that physicians “were asking for the ability to use the system, well in advance, but they really didn’t have [the system] ready.”
Providers were given basic training of the system, but it became clear to physicians that “the systems in place for training weren’t adequate and wouldn’t reflect on how the system was going to work.”
Forrest did his individual training with one of the physicians in charge of the CPOE system, and the message he received was: “We don’t know how this will work when we go live, we’ll have to learn on the go.”
Physicians were also told they could develop their own order sets as they went along and modify the screen to meet routine needs of patient care.
For example, as Forrest is an infectious disease doctor, ordering blood work is incredibly common. He wanted to create favorites in his workflow before the launch to make it easier to accomplish daily tasks.
“But the system was not available to do this until literally 24 hours before launch,” said Forrest.
Further, the ability to create modified workflows was apparently temporary, as the hospital decided to “homogenize orders,” and providers wouldn’t be able to create their own order sets.
Compensation also proved problematic, as Canada’s health system is made up of socialized health insurance plans that insure all citizens, and few Canadian providers are salaried. Physicians are paid on a fee-for-service basis, which made it difficult for IHealth to determine how to reimburse doctors for time spent on training.
“As we’re not salaried, we’re only paid for clinical services,” said Forrest. “[The health system] suggested training, where we would be paid by credits -- and not paid cash. It took a bit to pay physicians for their time.”
“We wanted a real opportunity to play with the system, but were given no financial incentive,” he added. “And doing so would take away from clinical income.”
There were problems in the order entry process as soon as it went live, said Forrest.
“Medication orders would go missing. And some orders would change the instant it was entered,” said Forrest.
For example, system limitations would force Forrest and other providers to continuously go back into the system to ensure modifications made to medication orders would remain. He explained that the EHR had a default that wouldn’t allow providers to change the dosing frequency.
Not only that, but his workflow screen would not match the pharmacy’s or the nurses’ for the same patient.
“I would enter the order correctly, and they wouldn’t see it on their screen. As a result, clinicians wouldn’t see necessary orders,” said Forrest. “While that particular problem was addressed, there are others that [IHealth] has been slow to address.”
Issues with medication orders are a huge safety concern, especially when it comes to blood thinners and insulin. Forrest explained these are medications that can cause major problems if under- or over-dosed. So much so that these are often micromanaged.
In fact, there was a patient with an insulin order set through an infusion as he had a severe elevation of blood sugar, said Forrest. While there was an order set available, it had to be tweaked to allow the order to continue for an extended period of time. However, it wasn’t a permanent fix, and it continued to be problematic.
Those in charge of the EHR project watched the provider put in the order to make sure it was done correctly. And sure enough, Forrest said the screens would change and the clinician’s screen did not match the provider’s for the same patient.
The IHealth team said it fixed the problem, but Forrest said that 10 months later the same thing happened with a patient who had high blood pressure.
“It shows [the IHealth team] just created a workaround for the problem, but didn’t actually solve it,” said Forrest. “It’s an indication that there are serious issues with how the system works.”
But it’s not just the computer program itself. Forrest said, “It’s human interaction when there’s a problem with the platform.”
“Most EHRs are cumbersome and complex in terms of entering simple orders,” said Forrest. “Before we could easily add notes to clearly state intent.”
But when providers attempt to add notes to the record, it can take 5 to 10 minutes and customized entries into the system can get buried in the workflow. Further, if someone downstream misses a step within the EHR process, clinicians can easily miss provider notes because there’s no clear way to view it.
“EHRs are complex, and it’s difficult to do things right,” said Forrest. “It’s not unique to Cerner… But systems too complex lead to human error. It’s almost a guarantee you’re going to have errors.”
“We need to have EHRs, but the fundamental error is that they’re based on billing software and not clinical needs,” he added. And for a nonprofit health system, an EHR platform that lacks consideration of clinician needs has caused many of these issues.
CHICAGO – Telehealth projects look different depending on the healthcare organizations putting the technology to work and the goals they're hoping to achieve, said Sue Schade, former CHIME-HIMSS CIO of the Year and current principal at StarBridge Advisors on Tuesday.
She should know. Recent years have seen her working at four major health systems with four different strategies and priorities for rolling out virtual care capabilities: Partners HealthCare, University of Michigan Health System, University Hospitals and Stony Brook Medicine.
Along the way, Schade has learned some lessons about what it takes to get a program launched.
Most people think of telehealth as a useful innovation for remote or rural areas, but as was emphasized over and over at the HIMSS Pop Health Forum, where Schade spoke this week, one of the biggest challenges to population health is often a lack of reliable transportation options, even in busy metropolitan areas.
Schade's previous employers – in Boston, in Ann Arbor, in Cleveland, on Long Island – showed that telehealth could be a valuable tool for patient engagement in urban or rural settings alike.
But each health system had its own unique set of challenges and opportunities as it worked to get remote care initiatives up and running.
At Boston-based Partners HealthCare, where Schade was CIO of Brigham and Women's Hospital for more than 12 years, the program was pioneered by innovators such as the renowned Joseph Kvedar, MD, founder of Partners' Center for Connected Health.
There, program leads did "a really good job connecting innovators with the operational leaders – to try to find out what kind of problems they could solve with the various solutions they were able to test and deploy," said Schade. "You really had a model there of an innovation center connecting up to operational issues."
At Michigan Medicine, formerly known as University of Michigan Health System, Schade worked for three years at a world-class academic medical center that employs "some of the best physicians, specialists and subspecialists" and served patients from every county in the state.
But one challenge there, she said, was that a more "academic approach to telehealth" was often built on existing departmental services that were each "doing something on their own, supporting it themselves with their own tools but not looking to coordinate or leverage any central program," said Schade. "They struggled with the strategy, how to organize, who should lead it."
Another lesson there had to do with electronic health records, she said. The health system is on Epic, but had to interact with "so many more institutions (that) didn't have Epic," she said.
The lesson: "If you're going to leverage your core EHR for your telehealth work – which I encourage you to look closely at doing – take it as far as you can, but it will only go so far and you will be working with other institutions in the geographic area that don't have that same EHR, just as you do with HIEs."
"You really need to focus on strategy. Understand what your business drivers are. And from that specific programs will become clear"
Susan Schade, current principal at StarBridge Advisors
At Cleveland-based University Hospitals, where Schade spent 10 months in 2016 as interim CIO, said one of the motivators for telehealth success was to keep pace with the ever-innovative hometown competition, Cleveland Clinic.
UH had an emerging program, had instituted governance and had several pilots, she said, but "the challenge was having a clear strategy and program that was right for them – and not just thinking about the competition and that they were trying to keep up with the Cleveland Clinic."
At Stony Brook Medicine, in the middle of Long Island, the key was also to ensure the program was the right fit for its own goals. The health system tended to focus on populations on the eastern, more rural half of the island (compared with competitor Northwell Health, which primarily serves patients in denser Nassau County and into Queens).
Schade spent six months as interim CIO at Stony Brook earlier this year, and said a key driver was "having a strategic view in their east-looking strategy" and tailoring their program accordingly, she said. "Where does telehealth fit into their population health goals for that community?"
Know your goals, get docs on board early, use a common platform
That, said Schade, was one of the key takeaways for anyone considering launching a telehealth program. Don't do it just for the sake of it – know what you want to achieve, and how you want it to fit into your hospital's larger mission.
"You really need to focus on strategy," said Schade. "Understand what your business drivers are. And from that specific programs will become clear."
Another must-do? "I can't emphasize enough the importance of physician leadership," she said. "They are the ones delivering care, they will be the ones delivering any forms of telehealth, so they really need to be in the middle of it. IT cannot lead, it has to be a partnership."
Foresight and strategic planning across the enterprise are critical, said Schade.
"A lot of planning goes on. You need to form your oversight group, you need to identify what your priorities are. It's important that you bring in the right operational people from a billing and reimbursement (and) legal perspective. People who manage access. All of those folks need to be at the table and part of this."
As for technology, "it's very important that you look at a common platform and tools." At Michigan Medicine, "a lot of activity was already going on," she said. "You to inventory in a situation like that: Who's already doing what? What tools are they using? What services are they providing? Can we bring that together, can we consolidate?
"And then how are we going to leverage the core EMR vendor?" she added. "All EMR vendors, they may be in different places, but they're all trying to something in this space. So you need to figure out where they are, what their roadmap looks like and how far you can take them before you start bringing in a lot of bolt-on products."
Ultimately, said Schade, "you need to commit and invest. This cannot be a one-off or a hobby. It takes time. It takes money. Pilot, then scale up. There's a lot behind the scenes that needs to get done and invested in. In terms of an overall budget, the whole area is kind of fluid. So you need to have some kind of placeholder, baseline budget to start with and then let it evolve over time."
Read our coverage of HIMSS Pop Health Forum in Chicago.
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⇒ Human-centered design expert shares 4 tips for engaging patients
My personal realization of the frustrating lack of communication and information sharing among providers in the U.S. healthcare system began back in 2003. At the time, I was living in a suburb just south of Pittsburgh and I started to experience what I thought was a bad urinary tract infection.
My first stop was a nearby Urgent Care Center. The physician there ordered a urinalysis. When that came back negative, he checked my prostate and ran some STD tests. Everything came back clean, but as a precaution, he put me on a two-week course of antibiotics and sent me home.
[Also: Read more #IHeartHITstories here]
The pain and symptoms didn’t go away. In fact, they got worse. I called the physician at the Urgent Care Center and he referred me to a nearby Urologist. This specialist ordered the same batch of tests the Urgent Care physician did, which produced the exact same results. His diagnosis? Chronic prostatitis (even though my prostate wasn’t inflamed and my prostate fluids all tested clean). He prescribed an even longer course of even stronger antibiotics that produced the exact same result: no improvement.
After a couple months of being unresponsive to this treatment, the urologist ordered a series of additional tests. Blood was drawn. Images were taken. Scopes were inserted into the most sensitive of areas. Guess what? Everything came back normal once again. The urologist in Pittsburgh stuck by his original chronic prostatitis diagnosis and ordered an additional course of antibiotics.
My symptoms never went away. The pain and burning were constant. Sometimes it was just mildly irritating. Other times, it was close to unbearable.
During this period, a career change caused me to relocate from Pittsburgh to Erie, Pennsylvania. Unfortunately, I didn’t leave the pain in the Burgh. It traveled with me to Erie, but my patient data didn’t.
Upon arrival in my new home, I started to see an Erie-based urologist and started the process of communicating my symptoms to him all over again. He began to order the same series of tests I had already been through in Pittsburgh.
“I’ve had all these tests performed already,” I said. “Can’t you just get this data from my old urologist in Pittsburgh?”
“No,” he said. “Our offices likely use different information and imaging systems, so I probably wouldn’t be able to read the data. Plus, I like to run my own tests to ensure they’re done correctly.” (Sure you do. Plus, you can charge for each service you order too. Why pass up easy revenue?)
So, once again blood was drawn, images were taken and scopes were inserted into the most sensitive of areas. Guess what? The results were exactly the same. All test showed that there was nothing wrong with me. But, still the pain persisted.
This cycle continued itself for more than a decade. My original urologist in Erie finally said he couldn’t help me and I went to see another. This new urologist ran the same battery of tests (yet again), which produced the same results. This doctor had the idea that maybe my symptoms weren’t related to my urinary tract at all but was referred pain from a colorectal disorder.
He referred me to a colorectal doctor who I had to explain my symptoms to (yet again) and he ran a different battery of tests. Blood was drawn. Different images were taken. Scopes were inserted into different, but equally sensitive, areas. Still, all tests came back negative.
It was frustrating enough to have to live with the pain for which no doctor could find a cause. It was even more frustrating when some physicians told me the pain was likely all in my head. However, perhaps the most frustrating thing of all was having to repeat my story over and over and over again for every doctor I saw and having the same battery of uncomfortable tests performed countless times.
None of the doctors I saw ever spoke to one another or shared any of my prior medical tests of information. My medical history became fractured, siloed episodes that remained in the possession of the physician’s offices in which they were conducted. Each time I saw a different doctor, I was back at square one — forced to start the whole process over again. This disconnected, repetitive and inefficient healthcare environment is at complete odds with the best interests and well-being of patients. There has to be a better way, and health IT needs to play a key role.
This personal medical journey has galvanized my passion for helping educate healthcare providers to build open technology systems and infrastructures that enable easier information sharing while allowing patients to ultimately own their healthcare data. EHRs, Enterprise Content Management (ECM) and Enterprise Imaging (EI) technology will be key components of this infrastructure, but we still have a long way to go.
My story has a happy ending. My wife finally convinced me to travel two hours west to Cleveland Clinic (a provider outside of our health insurance network at the time). The doctors there diagnosed me with Pelvic Floor Dysfunction (PSD) — a condition that’s rare in men my age and one that never would have shown up on any of the numerous duplicate tests I endured over the years. After more than a decade of physical and mental suffering, I’m pleased to say that through periodic physical therapy and daily at-home exercises, I’m now mostly pain-free. The condition wasn’t one I psychosomatically manifested after all.
While my journey ended well, the long, torturous road I took to get there should never have happened. Unfortunately, not much has changed in the 14 years that have passed since my journey began. Today, patients across the country are enduring the very same repetitive narratives, paperwork and tests that I experienced. And, as such, they’re experiencing very similar frustrations.
The healthcare industry has made some progress in regards to capturing and sharing information via EHRs, but much of this data is still incomplete and incapable of being shared outside of the healthcare network in which it resides. We need to continue to make strides to create interoperable networks that allow all of a patient’s valuable data to travel with them from provider to provider. I hope with every passing National Health IT Week that we continue to get closer to that goal.
– Ken Congdon is healthcare content marketing manager at Hyland, a HIT software company.
This National Health IT Week, HIMSS is giving the industry a platform to share stories about how health IT is progressing. We are at a critical point on the path to healthcare transformation in the U.S. and policymakers want to know if we are making progress. Share your story and help impact policymakers.
When Mount Sinai Hospital set out to upgrade its clinical workflow in 2005, the IT team estimated it would be a three-year job. The scope of that project was to replace the paper charts and an aging GE Logician system at the New York City teaching hospital which was founded in 1858 and borders Manhattan’s Central Park.
What the original team didn’t plan on was the hyper-growth that was coming. In the years that followed, Mount Sinai merged with one of New York City’s largest hospital systems, Continuum, and now operates seven hospitals and 100 ambulatory practices. With more than 38,000 staff members, it has become the second-largest private employer in the city.
Through all of that growth, the Epic project is still underway with completion now scheduled for 2020. But rather than simply replacing paper charts with digital records, Epic modules have transformed every aspect of care throughout the system. Epic modules will be used in all departments throughout the system, including revenue cycle management.
The Mount Sinai team has no regrets about taking its time. It is proud that the process caused minimal disruption to clinical and administrative operations. Go-live events run smoothly and the platform has been embraced by physicians and nurses.
The Mount Sinai system, which includes the Icahn School of Medicine, has a prestigious record of medical discovery. Just in the last month, physicians have announced the following breakthroughs:
Susan Brassell-Knox, a senior director, attributes the success to having a Program Management Office working in partnership with the Epic IT team.
"Having a change management resource is critical."
“Having a change management resource is critical,” she said. The PMO team takes on a communications role throughout the project, and works to ensure that adoption goes well.
Launched in 2008, the PMO team is in touch with clinicians at all phases of the process. It holds frequent town halls, and engages even the chairs of the departments in the roll-out process.
“We need to make sure everyone knows this is coming, even if it doesn’t impact their department,” she said.
The merger with Continuum brought to the team the challenge of supporting “a mixed bag of EMRs” in the words of Ken Koppenhaver, senior director, Epic applications. At the different hospitals, which include St. Luke’s, Roosevelt and Beth Israel, support for eClinicalWorks and GE Centricity PRISM needed to continue as Epic transitions were planned. The team estimates another two years of work will be needed to complete the upgrade in all of the ambulatory areas.
Koppenhaver said the process of keeping legacy systems running during a period when the vendors know Epic is the future has been challenging. “They are not incentivized to solve problems,” he said. But there have been no serious difficulties.
"We made sure there was a major investment in infrastructure: emergency power, the network, Wi-Fi, the data center, making sure we had the right sizing of the servers to handle the capacity."
Some of the challenges stem from the need to continue running systems on a “very old mainframe” that occasionally need to communicate with the newer software. Mount Sinai continues to maintain its own data center.
Roll-outs of new Epic modules into different units have become almost routine.
“We’ll have go-lives in the ambulatory areas for the rest of this year and into the next,” said Elena Sethi, director, IT Program Management Office. One of the main projects right now is deploying Epic’s scheduling, ambulatory electronic medical record and professional billing modules.
Sethi said that the department has adopted a strong focus on change management techniques. They prioritize stakeholder involvement at all stages of the project.
“We’re putting our clinicians in front of the change,” she said acknowledging that the message wouldn’t carry the same weight if was coming from IT.
The change management methodology is continually refined, with best practices from industry incorporated into the playbook. “With every implementation we look at new elements to add,” Sethi said.
"We’re putting our clinicians in front of the change."
As new modules were selected, Mount Sinai did not simply go back to Epic. It performed competitive reviews and included clinicians in the evaluation process. In the end, it has stayed with Epic.
Last year’s rollouts were focused on scheduling and professional billing. But successful implementations required more than just software.
“When we went live we couldn’t have people saying I can’t find a PC to work on,” Koppenhaver said. “We made sure there was a major investment in infrastructure: emergency power, the network, Wi-Fi, the data center, making sure we had the right sizing of the servers to handle the capacity.”
The 950-member IT staff has 145 people devoted to Epic support. Citrix connects PCs into the EHR application and documents are managed through OnBase by Hyland.
The side benefits of having the system so tightly integrated are becoming apparent. Mount Sinai staff is doing work on population health and predictive analytics and they appreciate the availability of a “command center” dashboard that displays statistics like how many patients are waiting in the emergency department and how many patients are in the OR.
“We’re going to take that to the next step with data,” said Kristin Myers, senior vice president, information technology. “How do we predict patient throughput and capacity, how do we predict staffing, how does this impact patient care?”
One thing the team may be able to predict soon: a date when the Epic transformation is complete and the mainframe can finally be retired.
My Mom is 79 years old and lives alone in a retirement community in Southern California. During the night, she experienced tremendous pain from her hip and inner thighs, down to her feet. She was unable to stand.
A neighbor heard her cries for help and took her to the local hospital emergency room. She completed admissions paperwork, was seen by a couple of doctors and diagnosed with sciatica. They administered and prescribed pain medication, contacted her primary care physician (PCP), and she was discharged to her home. Her brother (who lives in San Diego), was able to get her there safely while I traveled from Arizona to care for her.
[Also: Read more #IHeartHITstories here]
She spoke with her PCP the next day and was referred to a local pain doctor. FOUR DAYS later, she met with the pain doctor, and his office needed her to complete the same paperwork required by the hospital despite the fact it appeared the pain doctor had some record of the hospital’s diagnosis & incident treatment.
She was in so much pain, she was borderline hysterical. As a result, the pain doctor would not examine her in her current condition. Rather, he ordered an MRI to pinpoint where the sciatica was originating –L4, L5, S1 or S2– with the intent to inject steroids to the appropriate location to alleviate the pain.
We were handed a written prescription for an MRI and another for more drugs. We dropped off the prescription at the local pharmacy and had to wait for it to be filled.
We experienced some scheduling challenges due to availability, which meant the MRI would be performed FOUR DAYS later. (This made a total of EIGHT DAYS since she left the hospital, with nothing more than prescriptions to mask the pain.)
When we got there, my mom once again had to complete the same paperwork as she did at the hospital and the pain doctor. After the procedure, we were told the results would be sent directly to the pain doctor the next day.
When we arrived back home, we received a phone call from the MRI organization requesting a copy of the prescription. I asked if they could reach out to the pain doctor to obtain it. They preferred we send it to them instead.
We had no access to a paper scanner or fax machine, so I took a picture of the prescription with my phone and sent it to them via email, with the image of the prescription as an attachment. I called to confirm they had received it. I then asked if we are on track to get the report to the pain doctor tomorrow. They said it would be Monday, as this was the end of the workday/week.
I called the pain doctor’s office Monday to confirm receipt of MRI report. Yes...it was received via fax, printed, and filed into her paper-based patient chart. We then scheduled a visit for Thursday that week because that’s the only day their office administers steroid shots.
Thursday came, and for the first time since the night when she was taken to the hospital, my mom was finally in good spirits. Again, we were asked to complete the same paperwork as we did during our first visit. While we were waiting to be called, the pain doctor came out to the waiting room, put his hands out to his side with palms up, and said to the employee behind the desk, “Where’s Dolores’ fax?” My Mom’s shoulders dropped, and she immediately began crying.
I stayed calm and explained that I had confirmed that the report was received on Monday and that it was in her patient chart, which I knew was in the adjacent room. I even offered to retrieve it, although I knew this was against their policy.
The front desk employee said he would get it, but rather than leave his chair, he called the imaging facility to request they fax the MRI report again. Twenty minutes later the fax was received.
Another 15 minutes later, the pain doctor reappeared. He grabbed the fax report off the desk, licked his thumb, turned to page 4 of the 15-page document, read for 3 seconds, and said, “Let’s go Dolores.” She received her shot a few minutes later…L4. Spirits up! He then prescribed a CT scan and my mom was told to follow up with her PCP.
The day after the steroid shot my mom felt some relief. The following day was even better. Eventually, she was back to her usual self.
After scheduling and availability issues, the CT was finally performed SEVEN DAYS later. We were challenged yet again with scheduling a follow-up visit with her PCP. Another SEVEN DAYS later, we arrived at the PCP. He was unable to locate the documentation about her visits and results. It was finally resolved, and the PCP gave her the ‘thumbs up.’ The repetition in paperwork, the hurry up and wait game, the lack of communication…the entire ordeal was disheartening. I think the hardest part was seeing my mom in so much pain. Even more frustrating is that I work in health IT, and I know that technology exists that can help solve these problems.
It is so hard for me to believe that we are still using paper-based fax technology to coordinate care. Don’t get me wrong; we have made definite strides in care coordination, and huge efforts are underway to establish connectivity between ALL providers so that information can flow easily, at the point of care. When it’s finally in place, providers will be able to make more informed decisions and their patients will experience better outcomes.
My mom’s health story was an important one to me. It gave new meaning to the word “interoperability." A word that I use almost every day at work has now become far more personal than what it meant before. It’s not just some patient, now it’s my mom.
During National Health IT week, I want to take a moment on behalf of me, my family and friends, to say THANK YOU to all who are focused on solving these critical issues.
– Rich Piper is vice president of sales for Kno2, a health IT vendor focused on data exchange.
This National Health IT Week, HIMSS is giving the industry a platform to share stories about how health IT is progressing. We are at a critical point on the path to healthcare transformation in the U.S. and policymakers want to know if we are making progress. Share your story and help impact policymakers.
Since athenahealth acquired RazorInsights in 2015, the vendor has made quick inroads into the realm of community hospitals, according to a new report from KLAS.
Athenahealth’s cloud-based EHR service, athenaOne for Hospitals and Health Systems, has become the third most frequently selected records solution in the country, both in 2015 and 2016, KLAS found.
The good news from KLAS is probably a welcome reprieve from a rough patches athenahealth has had this year, with an activist investor taking aim at the company and spurring the threat of a takeover, falling stock prices and speculation about who might buy the cloud-based company – Apple? Then there also was the specter of new competition from Epic, which is developing lower-cost versions of its EHR to take on athenahealth and others in serving smaller organizations.
KLAS interviewed all of the eight hospitals that contracted with athenahealth to convert from another EMR and went live by February 2017. KLAS also spoke with 28 other hospitals that contracted with athenahealth but were not yet live as of February to gauge their progress.
Hospitals that migrated from the RazorInsights platform were excluded from the research because their experience is atypical of what prospective clients might expect.
Executives at small hospitals are largely positive about their experience with athenahealth so far, KLAS found. They especially like the prospect of having an integrated clinical/RCM solution without a large up-front capital outlay.
Also, they said athenahealth’s innovative cost structure and web-based solution can help them stay financially viable and decrease IT and security resources in coming years.
Customers point to improved usability as the biggest success. The majority of customers surveyed (outside of pharmacy) say the athenahealth solution’s overall ease of use has been a win, especially for physicians.
They also note there is plenty of room for improvement on that score and also on documentation. Customers indicate the workflow is better overall than what they had before with paper or a previous EMR.
“The athenahealth report was produced to meet demand by community hospitals for information on a frequently-considered solution for migrating from legacy systems,” a KLAS spokesperson said. “It was driven by provider interest, not commissioned by a vendor such as athenahealth. Yes, athenahealth does have a relationship with KLAS and purchases access to KLAS research and consulting services. But no, athenahealth did not pay KLAS to conduct this research.”
You’ve probably heard that Epic Systems CEO Judy Faulkner wants to drop the E from electronic health records and replace it with a C.
“‘E’ has to go away now. It’s all electronic,” Faulkner said at the company’s user group meeting in late September. “We have to knock the walls down whether they’re the walls of the hospital or the walls of the clinic.”
Faulkner made something of a splash when she called an EHR a CHR, but, according to her, the letter change represents a big shift.
"Because healthcare is now focusing on keeping people well rather than reacting to illness, we are focusing on factors outside the traditional walls," Faulkner told Healthcare IT News.
Faulkner explained at the user group meeting three things Epic is thinking about in regards to a CHR.
“The first is that there’s information that’s not in the EHRs now. The second one is care that is not in the hospital but has to be part of the picture,” she said. “We bring them in the Comprehensive Health Record which should be the comprehensive health record – social and community care. And the last is traditional healthcare within the walls that has now moved out of the walls.”
To that end, and in contrast to today’s EHRs, the CHR would include more types of data, such as social determinants, about what people eat, how much they sleep, if they are obese or live in a food desert (or both), and whether they are lonely, because all of those factors can have an enormous impact on an individual’s health.
Another reason today’s EHRs must become more comprehensive is that other countries spend more money addressing those social factors. They end up with healthier people because of it, she said, such that the U.S. simply cannot afford not to include social determinants in patient’s medical history.
“If you want to keep patients well and you want to get paid, you’re going to have to have a comprehensive health record,” Faulkner told attendees. “You’ll need to use software as your central nervous system, and that’s how you standardize and manage your organization.”
The big question is whether Epic continues using CHR.
“Yes,” she said. “We think it should be the new terminology, replacing EHR.”
EHR vendor eClinicalWorks on Friday debuted Version 11 of its cloud-based electronic health record service, along with a new virtual assistant, a virtual room, and FHIR-based interoperability services.
Friday’s announcements come after a summer in which eClinicalWorks settled a landmark $155 million false claims suit over EHR certification and also announced new customers. And it also follows rival Epic’s mid-September release of an interoperability tool for patients.
The vendor said that V11 EHR brings new features and functionality created to improve workflow. It also introduced the eClinicalWorks virtual assistant EVA, designed so users can conversationally interact with the EHR. eClinicalWorks also unwrapped the healow Virtual Room, or VR, which enables clinicians and patients to consult via telehealth tools.
On the FHIR front, eClinicalWorks announced Open Interoperability and said the cloud service will enable customers to connect with other hospitals and networks. The new interoperability offering follows eClinicalWorks self-activation for CommonWell Health Alliance and Carequality Interoperability Framework. eClinicalWorks also announced a FHIR cloud service for developers to create patient-facing apps.
The eClinicalWorks V11 EHR will be officially available on Dec. 15, 2017.
Cerner will launch its fourth and final electronic health record pilot with the U.S. Department of Defense at the Madigan Army Medical Center on Oct. 21.
The rollout of MHS Genesis at Madigan is the largest undertaking of the pilot, as it’s one of the biggest military hospitals on the West Coast. DoD, Cerner and Leidos Partnership for Defense Health have already launched at Fairchild Air Force Base, Naval Hospital Oak Harbor and Naval Hospital Bremerton.
The Department of Veterans Affairs will likely be looking to this pilot for lessons, as it moves closer to securing its contract with Cerner for its own replacement of its legacy EHR Vista.
DoD, much like the VA, was an early adopter of electronic systems. But the agency’s ALTHA had disparate systems that couldn’t speak to each other and were expensive to maintain. Madigan employees -- like those from other DoD facilities -- have long grown tired with the outdated, legacy system.
“Most doctors want change tomorrow,” said Col. Eric Shry, MD, chief medical informatics officer at Madigan Army Medical Center. “There’s a huge amount of excitement by all the clinicians and staff.”
Preparation for the rollout began three years ago, although the DoD has been using EHRs for more than 35 years, said Shry.
“We approached this like a military mission,” said Shry. “There was a substantial amount of work required to standardize workflows between Army, Navy and Air Force, with over 700 workflow advisory groups creating the workflows that informed the enterprise build.”
While the medical center’s rollout plan reads like most civilian hospitals -- with training, technical and communications teams -- Madigan had one major difference. It used a military operations cell to connect 5,000 people spread out over hundreds of facilities and 60 miles.
Shry’s team focused on providing military orders coming from the commander to streamline incoming, necessary information about timing and activities related to the rollout.
“This allowed us to execute at a scale with reliability that would be impossible in civilian organizations,” said Shry.
But one crucial component is true to all providers attempting a major tech rollout: clinical informatics.
Madigan has one of the largest clinical informatics divisions in the DoD and the only DoD physician informatics fellowship program, which Shry said allowed his time to better plan, create and execute the necessary military orders.
Safety is paramount to the rollout, and the hospital is leaning on the support and experience from Leidos and Cerner to execute plans that will keep patients safe. Along with a Remedy ticket tracking system that includes 80 tags to be aggregated in real-time, Madigan will also implement adoption measures that will be constantly monitored.
“We have a detailed local and enterprise governance process in place to handle issues rapidly,” said Shry.
Security is top-of-mind
The biggest challenge of the Cerner pilot, much like all other DoD processes, is cybersecurity. The DoD poses some interesting safety complications, when you consider a shared environment where both combat drones and medical records exist in the same space.
“Daily massive threat of attack is our reality,” said Shry. “Our safety requirements are much, much, much higher than any organization in the world.”
Like most private sector organizations, one of Shry’s biggest safety concerns is medical devices. Medical device vendors have far “too long thought of security as an afterthought and doing any updates after FDA approval is seen as a cost, not an opportunity to improve patient (data) safety.”
“Vendors see outsourcing IT support to countries that are not our friends as a way to cut costs rather than a security risk,” he added. “We will not compromise our security or patient safety.”
As a result, the team at Madigan is leveraging significant resources to ensure the DoD has one of the most secure health IT systems in the world. And as the rollout date draws closer, Shry is working to overcome potential technical challenges -- like cybersecurity and network -- to ensure the system is secure.
Leidos and Cerner’s proven track record of success gives Shry some piece of mind, but said he is focusing more on potential issues as “implementing this proven system involves unique challenges.”
Overcoming workflow/platform challenges
One overall concern for Madigan is ensuring the transition from a legacy, government system to an EHR modeled on private sector needs is seamless.
“Higher level DoD concerns during transition are primarily not about care delivery but about changes in work process and data unification,” Shry said.
Included in Madigan’s system are more than 40 years of measures that are used to report to Congress and other agencies, which Shry is worried may not easily map to civilian EHRs. But the plan is to lean on a seven-year transition process.
Further, Shry and his team are using the Joint Legacy Viewer -- a clinical app that provides an integrated readout of health data across the VA and DoD -- to be able to view archived clinical data. But the real challenge will be comparing administrative and business performance from both legacy and modern EHRs.
“Civilian capabilities, like block appointments, do not fit neatly into the DoD access measures,” said Shry. “Patient activity-based accounting offers a significant challenge to work center and facility accounting that we have become accustomed to over decades.
“Adopting civilian norms will be difficult in the near term, but tremendously beneficial in the long term,” he added.
OurHealth, which assists employers in setting up, staffing and running on-site or near-site health centers, will use athenahealth’s EHR and practice management services to support its nearly 40 employer-sponsored clinics.
When it came to working with the information systems of varied employers as well as other information systems OurHealth itself needed, integration was key.
Athenahealth’s platform enabled OurHealth to build directly into other systems’ APIs, allowing for the integration of, for example, patient portals and Salesforce systems into athenahealth, said Sherry Slick, chief information officer at OurHealth. This enables OurHealth to connect the business data with clinical data to provide a complete picture of performance.
"Syncing patient demographics between the various systems facilitate efficient communication processes."
Sherry Slick, OurHealth
In addition, OurHealth tapped into athenahealth’s More Disruption Please marketplace, leveraging a digital check-in app called Yogi. The athenahealth platform enables integration of Yogi to better support the patient experience and free up front-office staff, Slick said. And OurHealth has an integration with a health information exchange in Indiana.
Having all of these internal and external systems integrated to its EHR has benefitted the employer health organization in a variety of ways, Slick added.
“Efficiency, collaboration, continuity of care and patient safety are key benefits of these integrated systems,” Slick said. “Syncing patient demographics between the various systems facilitate efficient communication processes. If a patient reports a cell phone number change via the patient portal, that information is propagated to athenahealth and Salesforce such that our clinic staff and member relations team have the correct info to call our patients.”
Appointment reminders, lab result notifications and referral services coordination all are dependent on having the correct contact information for a patient, she added.
“Clinical staff members are able to see the health coaching notes and goals from previous encounters,” Slick said. “When a member relation specialist is scheduling an appointment for a patient, they would be able to see from their Salesforce Patient 360 Console that a referral coordinator has been trying to reach the patient regarding a recent referral that has come from the providers in the clinics.”
Further, the accuracy of information, efficiencies and collaboration offered by these various integrations plays directly into facilitating continuity of care and improving patient safety within the clinics, she added.
OurHealth is able to see more patients at each site, improving the savings and experience it is able to provide to its clients and patients, Slick said. Most important, the increase in number of patients seen is not done at a cost to patient safety, she added.
“There is strong historical evidence that having a healthcare industry filled with disparate systems leads to operational inefficiencies, duplicative efforts, patient safety concerns and expanding costs to manage an ever-growing healthcare market,” Slick said.
In our third annual Healthcare IT News EHR Satisfaction Survey we asked hospital leaders, IT professionals and clinicians to rate their inpatient electronic health records systems.
Their answers are illustrative of the hopes and frustrations of the folks on the front lines, for whom EHRs have become an intrinsic and indispensable part of their work.
Questions included: How satisfied are you with the features of your EHR? What do you like best about the software? What would you change? How do you rate user interface and experience? How is its interoperability with other systems, and with medical devices? Security? Modularity? Vendor support services?
[Compare to last year: 2016 EHR satisfaction survey results]
The readers who contributed to our research run the gamut of hospital jobs: chief information officer, IT director, clinical engineer, application analyst, facility risk manager, telehealth coordinator, nursing informaticist and more.
As the inpatient market becomes ever more consolidated, it may not surprise you to know that those professionals tend to use just a handful of vendors: Epic (30 percent), Cerner (25 percent) and Meditech (11 percent). CPSI, Allscripts and McKesson – the latter two of which are now one and the same company– came in at a bit more than 5 percent of respondents each.
Overall, responses tended toward constructive criticism with suggestions on areas to build upon. It is a sign that innovation is taking hold among some products, and that certain EHRs are maturing into systems that users can appreciate.
What follows is our report on what hospitals want most from their EHR systems.
Surprise: Users are satisfied overall
Nearly half ranked their vendor at least an 8 out of 10 for satisfaction.
Perhaps counter-intuitively – given the semi-regular stream of studies claiming that physicians and hospital staffs widely dislike their EHRs, bemoaning them as burdensome data entry systems that distract them from patients – respondents to our poll actually seem fairly happy with their inpatient system.
When asked, "What was your overall satisfaction with the EHR system?" nearly 42 percent of respondents gave their system either an eight or nine on a scale of 1-10. More than 5 percent gave it the top "Most Satisfied" score.
Only 8.5 percent of respondents, meanwhile, ranked their satisfaction as a one, two or three on the "Least Satisfied" side of the ledger.
That says something. Most of the systems in use by the hospitals polled have the basic blocking and tackling down pat, and have more advanced features working fairly well.
Our survey showed EHR implementations scoring highest on interface/visual appeal (nearly half of respondents scored this an eight, nine or 10); security features (60 percent gave this one of the top three scores) and the responsiveness of vendor support services (more than 33 percent gave this a nine or 10).
Areas for improvement? Interoperability, both with other clinical systems (20 percent scored this a one or two) and with an array of critical medical devices (slightly better, with scores tending to be between five and eight), is not where most users want it to be. Same goes for the ability to accommodate modular features (a similar cluster of middle-of-the-road scores).
User interface and visual appeal
Users want a cleaner, more intuitive interface.
An area that seemed to receive special scrutiny was user experience and design. Asked what they'd like their vendors to do better, many users cited suboptimal user interface.
One said the UI is "too busy," which sometimes makes it "hard to find specific menus." Another said: "2017 version screens are too bright."
Those aren't just aesthetic concerns. Design choices can potentially impact patient safety: "Developers removed many of the lines and boxes to make the system appear sleek, but staff miss the lines and boxes," wrote one respondent. "Staff are struggling to read the font with our less expensive 22-inch monitors."
One survey-taker said the layout was "not intuitive for users," and another sought more attention to the system's appearance – specifically the "ability for end-users to customize their views, pages, etc. for their workflow." A third sought a "cleaner more concise UI," giving users the "ability to hide the functions they don't use."
Those who expressed favorable opinions of design and interface tended to be a bit more plainspoken – "visually appealing," "front end is ok," one person liked "the look.”
In terms of UX, users want fewer clicks, user-friendly features and “voice AI” functionality.
"Usability in some areas" is a problem, said one poll-taker, who asked for a workflow that didn't depend on so many mouse clicks, or at least a software where a "single click (is) allowed instead of having to double-click."
It’s worth noting that for the third year in a row, some version of "fewer clicks!" occurred over and over throughout the responses to our EHR satisfaction survey.
One respondent said the vendor should "make it user-friendly." It was clear, from his or her experience, that the system was designed for "billing and auditing, not about the patient.”
Turning that around, another reader argued that "when interfaces are accomplished they work like champs. It is one record – you can see what procedural areas document and inpatient areas document in one record. We like the best practice alerts and the medication alerts."
Other users liked certain specific features – everything from "pop up for forms, customization of pages and tracking boards" to the "ability to submit a range to view documents" to "ease of use and the ability to do some customization."
One, interestingly, thought it would be cool to have "a Siri type feature with voice recognition that would walk the clinician through documentation/order entry, etc."
Users want stronger security and a cloud vendor that can lock data down.
Despite its central importance to the storage, exchange and use of protected health information, security functionality got very little mention in our reader's responses, even as it scored fairly high across the board.
One user simply wished for "better security," without elaborating beyond that.
Another respondent who uses a cloud-based xpEHR, expressed satisfaction that security was not the concern of his team. "It is hosted at the vendor's data center," this respondent said. "They have to worry about the data security."
Users want flexible interoperability with medical devices, other software systems and apps.
Interoperability – both with medical devices and with other EHRs – was another story. It's still an area that leaves plenty to be desired, and the hospital staffers who took our EHR survey had lots to say about it.
A reader asked for "more interoperability over just integration." A third wanted "interoperability with other apps" outside the vendor's own modules.
"Greater flexibility and accommodation of team-based care," chimed in a reader. "Much better data extraction. Easier, more flexible, and more affordable data sharing and interfacing."
On the plus side, many IT pros and clinicians had some specific things to be happy about with their systems, especially those that were mature and well-connected.
One said the EHR was "fully integrated to include inpatient, outpatient, pharmacy, laboratory, radiology and other components. It also incorporates population health, women's health, pediatric, prenatal tools."
"Integrated applications provide a one-patient, one-record comprehensive view across all venues in our healthcare system," said another satisfied survey-taker.
When it came to medical devices, the numerical scores were marginally better, but also suggested there’s room for improvement.
"Better interoperability with devices," one respondent wished for. "Improve the ability to cross into different systems such as IV pumps and monitors smoothly," a second requested.
One reader wanted "better integration to receive discrete data from other clinical software systems – anesthesia meds and vital sign data, I&O; cath lab integration of the same information or intuitive workflow structure."
Integration with other modules, interoperability with outside apps, consistency in design.
As the to-do lists of hospitals evolve, so does the desire to soup up their EHR systems with bolt-on functionalities to serve those specific demands.
One reader wanted "interoperability with other apps" outside the vendor's own modules. Another suggested that vendors should more be more proactive about taking on that integration work, while a third requested "consistency in module design; total integration of all modules in the EMR."
A respondent noted that some modules are a little immature. "It's very hard when every module is built to look completely different," added a reader.
A poll-taker explained that eliminating of reducing functionality variances among individual modules could make troubleshooting a whole lot easier.
Quality of support services
Users want strong account managers, knowledgeable and skilled tech support staffers.
When challenges arise, it's helpful to have a reliable vendor support staff to help. Most respondents are satisfied with the help their vendors made available.
"Great account managers, client success manager, support team and upper management," said one hospital staffer, while another lauded their vendor's support team, complete with an exclamation point: "implementation processes and staff excellent!"
One liked the skill set and knowledge" of the support staff, especially the efficiency with which they were able to do updates on the system.
Naturally, some customers were dissatisfied. One wanted "seasoned support resources," "less staff turn-over," or "better support backend." More harshly, a reader said the vendor’s “support is no good, they’re a monster.”
Overall, the positives certainly shined through in this year's survey. For every frustrated end user who said their EHR was "so convoluted that even the company has trouble figuring it out" it's gratifying to remember that there are others who are satisfied with the systems they log into and work with every day.
Could it be that years of frustrations with inpatient IT system notwithstanding, hospital staffers are finally starting to … like their EHRs?
Let's see what next year's survey finds.
Electronic health records vendor drchrono has debuted a new enterprise unified task management application that now is available within the company’s EHR.
The unified task management application is designed to improve workflow for physicians and staff, enabling them to create tasks, including recurring tasks, from wherever they are in the platform. Physicians and staff then can assign tasks to teams or groups of individuals, such as the front desk team, and have information automatically populate directly in the specific task.
Caregivers can attach lab results, clinical notes, medications and refill requests to a task. Launching a task within the EHR enables the task creator to pull in information with context from the relevant screen they are on. For example, if a doctor is working on a specific patient’s chart and they need to create a task for a medical assistant, the physician can import all of the relevant information with a few clicks or taps, not having to retype any information.
Further, drchrono’s new task dashboard gives the practice a view of all open and closed tasks, showing statuses and priorities and the time it takes to complete a task. The task dashboard, for instance, can show where a specific task is taking too much time and needs to be optimized.
Also, care teams can see when a specific group of tasks are urgent; tasks bubble up to the top of the dashboard for a team to see what needs to be completed first.
“The new task management provides a much more sophisticated workflow for larger practices that are reviewing large amounts of patient data, taking copious notes, and filling medication and lab requests daily, and want to do it all in a more efficient manner,” said Daniel Kivatinos, co-founder and COO at drchrono. “Our end goal for this is that a practice using task management would be able to do complex workflows.”
For example, Kivatinos said, a patient walks into a practice, the doctor sees the patient, the physician triggers a lab test for a blood draw, which triggers a staff member to draw blood, then sends the request to the lab.
Once the patient’s lab results are back in drchrono, he added, the task triggers the next step, for the physician to review the labs, then alert the staff to call the patient to come back in to review the labs with the physician in person.
“This would greatly improve efficiencies and information flow for both the practice and the patient,” he said.
The unified task management application also includes: real-time reminders and notifications for staff, for example, push notifications from iOS; triggering tasks from the provider filling out a medical form, for example, a physician can trigger a task that can be created automatically to schedule a follow-up visit; adding subtasks within tasks to create more complex workflows.
John Quackenbush believes data is the currency for all scientific advancement, driving conclusions and even improving the practice of medicine.
“But the challenge is that when we really look at what data is available, often the data is incomplete or inaccessible or not in a readily usable format,” he said.
Quackenbush, professor of computational biology and bioinformatics at Harvard Medical School-affiliated Dana Farber Cancer Center, worked on the Human Genome Project and did a two-year stint at Stanford University exploring the intersection genomics and computational biology. So his focus is primarily on the large and fast-growing galaxy of genetic data. But his words hold true for any type of clinical data, in electronic health records and beyond.
At the HIMSS Big Data and Healthcare Analytics Forum on Oct. 23, Quackenbush's keynote address will explore ways data can be made more accessible, usable and valuable for improving care. It's a prospect, you've probably noticed, that's not as easy or clear cut as it might sound.
"Our ability to make relevant inferences from the genome is still limited," said Quackenbush. "And what it's limited by is that the genome sequence by itself isn't enough. We need to know something about the health and health status of each individual whose genome is sequenced if we ever want to get to the point where we can draw meaningful conclusions."
In other words, he, said, "the real challenge we face moving forward is not a dearth of data but instead a wealth of data with incomplete metadata."
Add to that the challenging fact that healthcare's tools and techniques still aren't always up to the task of sifting through the mounds of digital insights we've amassed, and the challenges become even more acute.
"There's a lot of useful data in EHRs, but the technology has not kept up with what we really need."
John Quackenbush, Dana Farber Cancer Institute
"There's a lot of useful data in EHRs, but the technology has not kept up with what we really need," said Quackenbush. "There was a really big push to implement them, but part of the challenge is they're very useful for some things but not very useful for everything."
Consider genomics: As Beth Israel Deaconess Medical Center CIO John Halamka, MD, has joked, most EHRs relay precision medicine data using "highly interoperable standard for such material called 'PDF.'"
As Nephi Walton, MD, assistant professor of genomic medicine at Geisinger Health System has pointed out, typically whole genome sequencing generates about 100-200 gigabytes of data, which is then distilled down. The rest of that data is "not totally thrown away, it's still at the lab," said Walton, but "essentially we're throwing it away – in large part based on the fact that we don't have a place to put it or an easy way to use it."
Genomics, of course, is highly specialized, data-rich and complex. But even on the more basic level of day-to-day clinical care, Quackenbush says IT systems are limited.
He tells the story of a time not long ago when he was struck a spell of intense dizziness. The room was spinning. He could barely make it to the phone. He eventually made it to the ED, where his vertigo, thankfully, was diagnosed to be loose calcium crystals in his inner ear, which clear up on their own.
But Quackenbush arrived at his office the next morning to a phone call from his primary care physician, who wanted to follow up on what he thought had been a cardiovascular episode.
"The hospital had run an EKG so what they did was annotate me as someone who had a cardiovascular event so they could get reimbursed for running this test," said Quackenbush. "That's symptomatic of the challenge of EHRs. They're designed to help the hospital in its main enterprise, which is getting paid for the services they render. It's a tool for tracking patients for reimbursement, more than medical care."
Similar challenges arise when analytics tools are applied to data without strategic thought about how they're put to work, and what hospitals hope to accomplish.
"With a lot of analytics, people apply it blindly without thinking, is this the appropriate tool?" said Quackenbush. "I can use a wrench to loosen a bolt. Or I can use a wrench to pound in a nail, which is not the best use of the wrench. Either one of those applications doesn't make it a good or bad tool. It's a good tool for what it was designed to be used for."
Consider artificial intelligence: "There's been a tremendous amount of excitement about AI and machine learning," he said. "There's also been a good amount of hype. I work in a domain where some of my colleagues use machine learning tools in an emerging field we call radiomics: You look at quantitative images, look at CT scans and you can extract quantitative features. We can use those to make predictions, we can use them as biomarkers,” he said.
"Machine learning tools are exquisitely good at things like tumor segmentation, and the reason is you have a simple yes or no answer," said Quackenbush. "It performs so well because you could get 10,000 images that a really highly qualified radiologist has gone through and circled the tumor. You have training sets, you have data, you have truths."
Indeed, machine learning can often outperform humans, and when radiologists use the tools correctly, there's "tremendous promise for applications like that."
On the other hand, sometimes machine learning isn't the miracle cure some expect it to be, either because it's being used for the wrong problem, or because it's being fed inadequate information.
Cognitive computing stumbles when "we don't have the right data to train an algorithm," said Quackenbush. "There's an interesting discussion. You don't have a system that's learning from the data to make predictions about what the best therapy is, you have physicians interpreting clinical guidelines and papers to make associations that the machine can then carry forward.
"Why does machine learning fail? It's because we don't have data on thousands of patients, all of whom have the same mutation," he said. "If we had all that data we might have the ability to train a really robust algorithm. But we don't. And so absent that data, using machine in this context just isn't using the right tool for the right job."
EHR vendor eClinicalWorks on Tuesday announced its support for OpenNotes, the healthcare transparency and patient engagement initiative launched in 2010.
Earlier this week, the company announced an array of new technologies. In another bit of news, as eCW works to put this past spring's Department of Justice settlement in the rearview mirror, the vendor says it now will enable providers to more easily share visit notes with their patients using its patient portal.
The move will help more than 130,000 providers using eClinicalWorks to build stronger relationships with their patients, officials say, and help those patients be more in control of their healthcare data.
OpenNotes launched seven years ago with pilot projects at Boston's Beth Israel Deaconess Medical Center, Pennsylvania-based Geisinger Health System and Harborview Medical Center in Seattle.
Since then it has expanded dramatically, with health systems such as Kaiser Permanente, Mayo Clinic and the U.S. Department of Veterans Affairs, as well as vendors such as Allscripts, Cerner, Epic and Meditech all participating in the project.
By offering visibility into their clinical notes, eClinicalWorks' cloud-based portal will help patients gain insights into their care and encourage them to work more closely with their physicians on healthcare decision-making.
Patient portals are a convenient, secure tool for empowering patients while reducing clinician workloads. This solutions brief shows how successful primary care practices have gotten patients to register for and engage with their portals.
HIMSS on Tuesday issued a firm call-to-action for interoperability with a focus on secure data exchange and improved access to information.
“We must achieve secure, appropriate, and ubiquitous data access and electronic exchange of health information,” the association said in its HIMSS Call to Action: Achieve Nationwide, Ubiquitous, Secure Electronic Exchange of Health Information. “Now is the time for bold action,” they said.
To that end, HIMSS outlined these specific calls to action.
1. Integrate interoperability approaches and trusted exchange frameworks.
HIMSS called on Health and Human Services to achieve semantic interoperability and data access with the goal of achieving higher-quality and cost-effective care delivery. Many providers today have little choice but to take a multi-pronged approach to health information exchange, even though examples such as Carequality and DirectTrust demonstrate collaboration is already underway.
2. Educate the healthcare community to implement standards and data formats to build an integrated approach to care.
HIMSS said HHS and ONC must support health IT community and standards development organizations in supporting new and non-traditional data types such as social determinants, public registries, genomics, quality reporting and environmental science. “Education is pivotal to ensuring that these data are based on known and adopted standards; standards that will continue to drive semantic interoperation and value for the broader healthcare community,” they said.
3. Ensure participation from across the care continuum including patients and caregivers.
While existing frameworks focus on ambulatory and acute care settings, gaps remain elsewhere, HIMSS said. “HHS should include consumers, patients, caregivers, payers, public health and non-traditional provider groups (i.e., community-based providers, long-term/post-acute care), in these interoperability approaches and trusted exchange frameworks,” HIMSS wrote. “There is a tremendous need to better understand how all healthcare stakeholders can participate in these efforts, the value of the actors in these models, and identify the business and legal exchange agreements needed to further advance ubiquitous semantic interoperability.”
4. Identify minimum necessary rules for trusted exchange.
These include business, legal, privacy and technology rules that should forge a framework for trusted exchange that makes it easier for health entities to participate and enables care coordination. “HIMSS urges the use of the Health Information Technology Advisory Committee to facilitate this work, allowing for and obtaining public comment and feedback throughout the process.”
5. Standardize identity management approaches.
Secure data exchange and integration is unrealistic without strong identity management. To that end, the industry needs a common framework for patient identity matching that spans trusted exchange solutions. “We advocate for the community to identify, test, adopt and implement standards and their respective algorithms for matching patients to their data across and between clinical and claims data sets.”
6. Improve usability for care and research.
This must be a priority for the health IT industry and HHS to earn the engagement of caregivers, physicians and patients alike.
“Improved usability would ensure that data are consumed discretely, incorporated seamlessly into workflow, help enable clinical decision-making, allow secondary use of data for research, and limit the burden on the end-user. This enhanced exchange is fundamental to promoting patient safety, achieving quality outcomes, facilitating care coordination as well as transitions of care, and controlling costs,” HIMSS said.
The U.S. is in the midst of a national crisis when it comes to opioid misuse and overdose. Last year, 52,000 people died from a drug overdose -- 33,091 of which were caused by a prescription or illicit opioid, according to the Centers for Disease Control and Prevention.
And 12 million people misused opioids in 2016, SAMHSA found.
While the President proclaimed in August that he thought the opioid crisis was a national emergency, he’s not yet taken the necessary legal steps to actually make a difference in the uphill fight against the epidemic.
For example, a federal declaration would ease restrictions on who can prescribe medications used to treat opioid addiction, while providing extra funds from disaster relief. But while the White House is still processing an “expedited legal review,” there are health IT vendors pursuing a private sector effort to thwart the overprescribing and overdosing of opioids.
There are a variety of vendors in this space attempting to make an impact in the crisis, and we’ve highlighted those with the most unique or largest presence in the sector.
SPR Therapeutics: Tech in lieu of meds
SPR Therapeutics’ SPRINT device is a drug-free wearable that uses a thread-like wire and wearable stimulator to alleviate pain. In doing so, the device could replace the need for opioids in some cases.
A provider inserts SPRINT’s thread-like wire through the skin into the nerve closest to the pain center and can be used for up to 60 days. The only item inside the body is the wire and an external stimulator is worn outside on a pad.
“At the end of treatment, it’s removed. And what we’ve found is it’s not only effective, there’s significant pain relief and improvement of the quality of life,” said SPR Therapeutics CEO Maria Bennett. “And for many, there’s a sustained effect after the device is removed.”
The FDA approved SPRINT for both acute and chronic pain. But at the moment, SPR is concentrating its efforts on fighting pain associated with knee replacement surgery. Many patients will put off knee replacement for fear of post-surgical pain, and the likely need for prescription pain medication to find comfort during recovery, said Bennett.
SPRINT uses a neurostimulation platform, which has been used for decades for many different types of uses. Bennett said it’s one of the lowest invasive approaches to ease pain. However, it’s often leveraged on patches that focus on pain centers, but must go through the skin.
“It doesn’t get down to the root of the pain,” said Bennett.
Alternatively, there are neurostimulators, which are about the size of a stopwatch and surgically implanted. It delivers mild electrical signals in the epidural space near the spine by thin wires. While this is an incredibly effective method, it’s also expensive and invasive -- making it a last resort treatment.
But SPRINT is designed to fill the gap in the middle of these treatment options, said Bennett.
“There are no tech options that are minimally invasive and with minimal cost to the provider or patient.”
“Opioids are filling that gap right now, so physicians and patients turn to opioids to deal with chronic pain. There isn’t another viable option,” she added. “We need something to map that pain. Opioids have served that purpose, but now we’re in crisis mode.”
SPR’s idea is to leverage less invasive tech, which providers can offer as an alternative to prescribing opioids. Bennett said there is no harm to patients to trying SPRINT to deal with pain, before opioids are considered. The most adverse event experienced by patients is skin irritation at the external stimulator placement.
To Bennett, SPRINT could also be used down the line to help those already addicted to opioids to ween off the drug. But SPR is currently channeling its efforts into given providers and patients an alternative to using a prescription.
SPR launched its efforts at the beginning of this year, but Bennett said the hard part will be selling the device to hospitals, providers and pain centers. The device has been approved for use by several pain facilities, and the company is hoping to build from there.
Surescripts: Dominant e-Prescribing network
Surescripts is a health information network that connects pharmacies, providers and benefit managers to provide real-time data at the time of prescription. Since 2001, the company has worked with the pharmacy benefit manager industry to digitize the prescribing process.
The software sends patient medical and prescribing history to the provider when a prescription is requested. The idea is to inform the provider whether a patient has a history of receiving an abnormal amount of opioids or is known to doctor-shop to obtain painkillers.
All major PBMs and pharmacies are connected to Surescripts, while almost all EHRs are capable to connect with the software. So far, nearly 1 million prescribers are connected to Surescripts and 230 million patients are covered, according to Paul Uhrig, chief administrative officer at Surescripts.
E-prescribing better informs the provider, due to access of a complete medical history, said Uhrig. “It’s important for the opioid epidemic as it gives the provider a better view of what they are prescribing, whether the patient has been doctor shopping or doubling up on drugs.”
“It’s valuable to inform prescribers and caregivers,” he added. “The data isn’t dependent on our network -- it’s coming from the pharmacy network.”
Surescripts is quickly working to fill any data gaps, which stem -- not from data sharing -- but in independent pharmacies that may not participate in the program, explained Uhrig.
Further, Uhrig said Surescripts is working to educate providers to enable them to use the system, as many don’t realize it’s legal. In fact, the DEA finally began to allow e-prescribing, and last summer, the last state changed its laws to accept the platform.
The DEA allows specific processes to ensure the person using the system is who they claim to be and is allowed to prescribed what is being requested, said Uhrig. And some states are now mandating e-prescribing, like New York and Maine.
“But even without a mandate, most pharmacies are capable of receiving an electronic prescription of a controlled substance,” said Uhrig. “Where we still have opportunities is in the provider community.”
In fact, in 2016 only about 14 percent of prescribers were required to use e-prescribing. Uhrig explained that many providers were watching to see how policies would turn out, but now at least 10 states have implemented or plan to implement laws to mandate e-prescribing.
“It’s getting that actionable intelligence into provider’s hands and using more secure means to prescribe opioids,” said Uhrig. “We’re beginning to see the alignment in the policy world.”
Imprivata: Prescriber verification directly in EHR workflow
On the surface, Imprivata’s platform is pretty straightforward: enable providers to securely access, communicate and share patient information using its OneSign platform. But the tech proves more than valuable when it comes to validating who is prescribing what type of medication.
“The best way to describe it -- we provide tech that allows for electronic prescription and controlled substances that is a more transparent form of prescribing than with paper,” said Imprivata Chief Medical Officer Sean Kelly.
“The issues with paper prescribing are potential fraud and abuse,” he continued. “We link directly with e-prescription right in the middle of the EHR to allow prescribers to use the tool from the workflow.”
The system providers a secure method to verify the provider has been credentialed into the system, said Kelly. To authenticate, the prescriber must provide two modalities when attempting to prescribe a controlled substance.
“Once the provider provides two modes at that point, then and only then does the prescription route to the pharmacy,” said Kelly. “There are a number of steps within the tech that meet DEA requirements.”
The enrollment process for prescribers is stringent, and at least one witness is required during that time, Kelly explained. The prescriber must provide a verified ID to be credentialed, and Imprivata will then provide a token system that is approved by the DEA. Those tokens vary by the healthcare organization.
Imprivata’s tech will also create a backend access control for that provider, which will creates a profile of the prescriber’s status within the EHR system that verifies the person is allowed to prescribe. While this process is complex, Kelly said that once enrolled, Imprivata’s tech actually streamlines and secures the prescribing process.
The company received independent certification from a third-party authenticating it’s DEA- compliant, said Kelly. Further, the platform also provides an audit of all medications prescribed, which makes it easy to write reports and insight into who is prescribing what and how much.
Imprivata also partners with Surescripts, which accepts the verified prescriber info and prescription needs and gives the ok to be sent to the pharmacy. Both companies are working together on thought leadership to educate the market on options and how to incorporate this type of tech into the EHR.
“The way I view it as an ER doctor, is we’re getting upstream of the problem and making it more difficult to prescribe inappropriately and making the process more transparent,” said Kelly. “It’s totally accountable and leverages safety mechanisms in place from e-prescribing models.”
LexisNexis: Shifting focus from what to who
While many of the vendors in this sphere focus on the prescriber end, LexisNexis works directly with pharmacists to verify the identity of the person picking up the medication.
We engage directly with pharmacies and work inside their workflows to ensure verification isn’t disruptive to the process, said Lizzy Feliciano, senior director of marketing for LexisNexis Health Care Solutions.
“Identity management platforms have a real role to play and can be deployed in real-time in the pharmacist workflow,” said Feliciano.
The platform generates questions for the pharmacist to ask that only the user would know. And Feliciano said the ID validation can be adjusted based on the significance of the prescribed medication. The verification tools pull from public records data and is able to take an identity and generate relevant questions.
The pharmacist doesn’t have free access to that data, but the platform generates the identity quizzes, explained Feliciano. The platform can also provide additional information, kiosks, biometrics and multiple mechanisms to verify the identity of the person prescribed the medication.
“The technology can be customized,” said Feliciano. “It’s just a matter of adoption. For us, it’s just making sure the pharmacy has the right tools.”
To Feliciano, what’s most important is that the key players in the sector have access to prescribing information right in the workflow. Further, these members need to be having real dialogue to understand what each vendor is bringing to the table to find real solutions to the crisis.
“When you think about health IT, you think of computers crunching data in the background,” said Feliciano. “But there have been enough advancements in health IT that [the necessary tech] should be in the workflow at the point of transaction. Rather than keeping us in the back room, we need to be in the hands of pharmacists.”
“We’re at the point where technology can provide those real-time answers,” she added.
While much the tech on the market to help healthcare tackle the opioid crisis has proven results, there are still some major hurdles to overcome before vendors can expect a major impact. Specifically, the issues surround technology, culture, education, policy, cost and insurers.
“Technology can be a separator,” said Imprivata Chief Medical Officer Sean Kelly. “Bad technology can make the problem worse, while good tech can improve the workflow.”
For example, if places are using technology that’s not directly connected to the EHR, the prescriber would have to go out of their usual practice, he said. And the other platform may not have a lot of the safety features of the existing workflow.
Interoperability is another common issue, as disparate systems can’t communicate, which breaks down data in the workflow, Kelly said. “It’s not just for convenience, but also from a safety standpoint.”
While the technology challenges are improving -- early on the biggest problem was streamlining the process -- Kelly said the issue now lies with culture change.
“Providers are used to the current system, but it’s an antiquated workflow,” said Kelly. “It can be difficult to change workflows to meet needs. But the flipside of that is that it’s an opportunity to rethink the technology.”
Much of the technology on the market is geared towards opioid prescription management.
Paul Uhrig, chief administrative officer at Surescripts, believes that if the industry can change its workflows to meet the needs of an ID proofing and two-factor authentication, it would be easier to leverage the technology. And through education, key members will begin to really leverage the capabilities of some of these technologies.
“What we’ve found is a lot of prescribers don’t realize that the technology [like Surescripts] is legal or that their EHR has the capability,” said Uhrig.
And that education needs to be a collaborative effort, said Lizzy Feliciano, senior director of marketing for LexisNexis Health Care Solutions. Key members in the industry must have real dialogue and understand what each brings to the table.
“We all need to be working to collaborate to bring this change to life quicker than we’ve been able,” said Feliciano. And there needs to be a better understanding of what’s needed to employ this type of technology.
“Even the healthcare community is far behind on its understanding of addiction,” said Leslie Dye, vice president, editor in chief of Point of Care Content at Elsevier, a data and analytics business. “Resources point to addiction as a disease, and it has to be looked at from that standpoint.”
And educational resources, like those found at Google and Elsevier, can also provide insight into available treatments, detox and recognizing addiction symptoms. To Dye, getting this information into providers’ hands can help them to make better-informed decisions.
To SPR Therapeutics CEO Maria Bennett, the real issue with prevention lies in cost and convincing insurers the tech is worth the extra price tag. SPR’s SPRINT tech could eliminate the need for opioids for some patients. But while the device is proven to be effective and has been FDA-approved, the real issue is that insurers don’t want to pay for it.
“How can we justify the cost from a payer perspective?” said Bennett. “We need to ensure we’re publishing good data to provide to insurance companies that validate the cost of the device.”
“Opioids are cheap, and it always comes down to the money,” said Dye. “Doing therapy for six months isn’t as cheap as handing someone medication.”
That’s the biggest obstacle to overcome, said Dye. We need to be working on policies and education to demonstrate that alternative treatments cost the insurer less in the long run and is better for the patient. This could be accomplished by incentivizing providers and insurers who prescribe these alternatives.
Further, it’s time the government made the switch to treat addiction as a mental health illness, explained Dye. For example, detox is necessary to help patients get off these addictive drugs, but long-term care is equally important.
Further, administrators must also be careful not to come up with great solutions, without input from the providers who will be enacting these changes, said Dye.
Kelly notes that a lot of efforts are out there to combat this pressing issue: PR campaigns, education, mental health funding and addiction treatment -- among others.
“But these are all high-cost interventions, but most are downstream of the problem,” said Kelly. “If you can prevent overprescribing and abuse -- prior to addiction -- it can have a really strong effect. And we’ll get more bang for the buck… Prevention rather than treatment.”