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- 12/03/13--10:19: _EHR Replacement: Do...
- 12/03/13--10:25: _Make ICD-10 Easier:...
- 06/20/18--09:16: _Atul Gawande to lea...
- 06/21/18--05:54: _CMS to host Blue Bu...
- 06/21/18--07:11: _Why Walmart filed a...
- 06/21/18--10:43: _CMS unveils new Dat...
- 06/21/18--12:26: _Medical group cuts ...
- 06/21/18--14:33: _Atul Gawande says A...
- 06/22/18--09:00: _The Holistic Patien...
- 06/22/18--09:10: _Radiology's Playboo...
- 06/25/18--07:31: _How Phoenix Childre...
- 06/25/18--08:49: _The next-generation...
- 06/25/18--10:11: _Poll results: Reade...
- 06/26/18--07:30: _Patient matching wi...
- 06/26/18--11:41: _VA to Congress: Fir...
- 06/27/18--06:35: _Next-gen interopera...
- 06/27/18--11:18: _Defining the strate...
- 06/28/18--06:35: _VA spent $3 billion...
- 06/28/18--08:54: _Cerner EHR project ...
- 06/28/18--10:11: _Next-gen health IT ...
- 12/03/13--10:19: EHR Replacement: Do It Right - An eBook Guide to EHR Replacement
- 12/03/13--10:25: Make ICD-10 Easier: Get Answers, Get Ready, Get Going
- 06/21/18--05:54: CMS to host Blue Button 2.0 Developer Conference this summer
- 06/21/18--07:11: Why Walmart filed a patent for blockchain, wearables and EHR data
- 06/22/18--09:00: The Holistic Patient Health Record: Image Enabling the EHR
- 06/22/18--09:10: Radiology's Playbook for Optimizing Imaging Informatics
- 06/25/18--08:49: The next-generation of healthcare tech
- 06/26/18--07:30: Patient matching will lead to interoperability, Pew says
- 06/26/18--11:41: VA to Congress: First Cerner EHR install will go live by 2020
- 06/27/18--11:18: Defining the strategic business goals for an EHR cloud migration
- 06/28/18--06:35: VA spent $3 billion over 3 years to maintain VistA EHR, GAO says
- 06/28/18--10:11: Next-gen health IT consulting: Moving into post-EHR era
Amazon, Berkshire Hathaway and JPMorgan announced the eagerly-anticipated head of their joint venture on Wednesday: Atul Gawande, MD.
Gawande has worn many hats over his distinguished career: surgeon at Brigham and Women’s Hospital, professor at Harvard's T.H. Chan School of Public Health, staff writer at The New Yorker, best-selling author.
The precise nature of the new venture, which the three companies announced earlier this year, is still largely shrouded in mystery. It doesn't even have a name yet.
But today three new facts emerged: It will be based in Boston. It will be an "independent entity that is free from profit-making incentives and constraints." And Gawande will lead it, starting on July 9.
"I’m thrilled to be named CEO of this healthcare initiative," said Gawande in a statement. “I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the U.S. and across the world.
"Now I have the backing of these remarkable organizations to pursue this mission with even greater impact for more than a million people, and in doing so incubate better models of care for all," he added. "This work will take time but must be done. The system is broken, and better is possible."
STAT, citing a note sent by Gawande to friends and colleagues, reports that he "is not giving up his positions at Harvard or the Brigham and that he will keep writing, including for The New Yorker. But he said he will transition from being executive director to chairman of Ariadne Labs, which works on solving problems in health systems around the world."
In addition to that work, Gawande has written four New York Times bestsellers: Complications, Better, The Checklist Manifesto and Being Mortal.
Despite the ongoing uncertainty about just how this new joint venture will continue to evolve, and indeed some skepticism about how much influence it will ultimately have on a sprawling, complicated and inefficient healthcare industry, it's clear that it's part of a wider trend toward disruption and tectonic movements – and that it would behoove hospitals and health systems to pay close attention to how it continues to play out.
Certainly, the hiring of an influential and widely-respected figure such as Gawande suggests the companies have big plans in mind.
"As employers and as leaders, addressing healthcare is one of the most important things we can do for our employees and their families, as well as for the communities where we all work and live," said JPMorgan Chase CEO Jamie Dimon, in a statement. "Together, we have the talent and resources to make things better, and it is our responsibility to do so."
"We said at the outset that the degree of difficulty is high and success is going to require an expert’s knowledge, a beginner’s mind and a long-term orientation," added Amazon CEO Jeff Bezos. "Atul embodies all three."
"Jamie, Jeff and I are confident that we have found in Atul the leader who will get this important job done," said Berkshire Hathaway CEO Warren Buffett.
The Centers for Medicare and Medicaid Services will convene its inaugural Blue Button 2.0 Developer Conference in Washington, D.C.
Kicking off on Aug. 13, the event seeks developers to work together building software, and sharing perspective for how Medicare claims data can be put to work improving health outcomes, according to CMS.
In addition to Blue Button 2.0, another goal of the conference is to continue innovating the agency's MyHealthEData project. Both initiatives were first announced earlier this year at HIMSS18.
"The inaugural Blue Button 2.0 Developer Conference will bring together application developers in the technical community to help build and develop new tools to help patients understand their health data,” said CMS Administrator Seema Verma in a statement.
The event will offer hands-on sessions for developers and others in the technical community to build upon their Blue Button 2.0 applications with help and real-time feedback from the Blue Button 2.0 team – as well as patient advocates and other experts. They'll be able to meet with CMS engineers and see demos about the ways other organizations nationwide are integrating with Blue Button 2.0, according to the agency.
To spur the advancement of its MyHealthEData initiative, CMS recently released four years of Medicare Part A, B and D data – type of coverage, prescriptions, primary care treatment, cost – for 53 million Medicare beneficiaries.
The agency says it wants to continue working with developers to make new apps that can help patients make better use of that Medicare data and more.
"This conference is the perfect venue for developers to network with each other and with leaders in the federal government to collaborate on ways to engage Medicare beneficiaries to make informed healthcare decisions," said Verma.
Walmart’s ongoing investigation of blockchain technologies seems to have intersected with its growing interest in joining the healthcare space, according to a patent application released earlier this week by the US Patent and Trademark Office.
According to the document, which was filed in December, the retail giant is seeking to protect a method that allows a patient’s EHR to be obtained from a blockchain database even if they are unable to communicate. Doing so would require verification from two different keys: a public key stored in a wearable that would be scanned by emergency responders via RFID, and a private key that is obtained by scanning a biometric signature from the patient.
The appeal of storing a patient’s EHR on blockchain is the relative difficulty of an unintended party accessing or modifying their data, the company wrote in its application. Both a public and private key are required to before the system will allow access to the patient’s record, with the private key being specific to each individual user.
“If medical records were stored on the blockchain, the private key of the patient would be needed to view/modify the records. In the case where a user is unconscious or incapacitated in an emergency, a first responder could not access the user's medical records stored on the blockchain,” the company wrote. “Thus, there is a need for a method and system for obtaining a medical record stored on the blockchain when the owner of the private key cannot readily provide the private key.”
The application envisions a number of potential form factors for the wearable device, such as a bracelet, a ring, or a necklace. This wearable could store the public key and the encrypted private key within a memory drive or, alternatively, house a version of the EHR that would be unlocked with both keys if a cloud-based storage solution is less desirable.
Accompanying this would be an RFID scanner, which scans the wearable to obtain the public key, and a separate biometric scanner device that would verify a bodily feature of the patient (at least a fingerprint, an iris, a retina, and a facial feature, for instance) to grant access to the private key. Taken together, the method would allow a care team or first responders to quickly access a patient’s complete medical record, while keeping the record itself inaccessible to others in the meantime.
Walmart’s interest in healthcare has become more apparent with each passing month. While last month saw a deal between the retailer and Sharecare, news broke in early April that the company was in talks to acquire PillPack, a New England-based virtual pharmacy, and expressed an interest in buying Humana.
Its forays into blockchain seem to be multiplying as well. After beginning tests with IBM’s platform in 2016, Bloomberg reported in late April that the company was prepared to implement the technology in its live food business. Further, the EHR patent document was accompanied by two other non-healthcare blockchain applications: a method for managing demand within an electrical grid, and another regarding access to real or virtual spaces.
The Centers for Medicare and Medicaid Services has announced what it calls the Data Element Library, aimed to help advance electronic health record interoperability in long-term and post-acute care settings.
The CMS database is free, centralized resource that allows users to see the specific data types that the agency requires nursing homes, rehabilitation hospitals and other post-acute care settings to collect.
Such data elements include demographics, medical problems and other types of health evaluations. Many of them have been standardized to be the same regardless of which post-acute care facility is using them, the agency notes.
In addition, the DEL includes the IT standards that support the collection of health information. CMS officials say having the standards and those data elements in one place as one-stop shop will make it easier for health IT vendors to incorporate them into the EHRs aimed a post-acute care providers, and that integrating those data elements will allow health data to be more easily exchanged among providers.
When patients move from a rehab hospital to a skilled nursing facility, for instance – or from an SNF to home care – their health records will move across care settings more easily as they're all "speaking the same language," according to CMS.
"We’re excited to add this important building block to the foundation for interoperability that CMS is helping to establish," said CMS Administrator Seema Verma in a statement.
"The DEL supports the use and sharing of data, and aligns with MyHealthEData, a governmentwide effort strengthening the interoperability of health information," she explained. "It also closely aligns with CMS’ Patients Over Paperwork initiative focused on reducing administrative burden and costs while improving care coordination, outcomes and patients’ ability to make decisions about their own care."
Part of Greenfield, Massachusetts-based Valley Medical Group's approach to healthcare is to ask each team member to work at the top of their job description. That means, for example, that the organization wants to have clinical staff doing clinical work, providers making clinical decisions and workflows as efficient as possible.
Some of the most time-consuming and least rewarding aspects of such work are the tasks that happen between patient visits, and this includes prescription refills. The previous workflow included routing refill requests to a clerk who would troll through a chart, collecting information on last previous visit, last refill date and quantity, last blood pressure, and any relevant lab results. The clerk would enter this data in the refill request, then route it to the ordering provider's assistant.
"This staff person would either approve the refill as a delegate or send it along to the provider to approve," explained Martha Mastroberti, healthcare informatics manager at Valley Medical Group. "While Valley Medical had refill protocols, they were inconsistently applied. They were not very efficient and sometimes resulted in a delay of medications for patients. In addition, pharmacies in the area routinely send additional faxed refill requests if they've not heard from us within 12 hours – creating more work and possible duplicate medications."
Valley Medical uses athenahealth as its EHR and found out about a medication management vendor called Healthfinch through athenahealth's More Disruption Please Marketplace, which means Healthfinch is already vetted and approved by athenahealth and will seamlessly integrate with athenaNet.
Medications are, obviously, one of the key components of healthcare today. As such, there has been a lot of development of health IT surrounding prescriptions. Medication management vendors include Allscripts, Cerner, DrFirst, GE Healthcare, Genoa Healthcare, Medication Management Systems, MedMinder, Omnicell, PointClickCare, Surescripts and Talyst.
Valley Medical turned its medication management system on for a handful of providers, not changing workflow at all, just asking them to be aware of the protocol status – In Protocol, Out Of Protocol, No Protocol, Duplicates – and to think about if they agreed with the status or not.
"Our next step was to continue to add more providers to the system while we customized the protocols," Mastroberti said. "We got to decide, for example, what visits were qualifying – not nurse visits, for example, or urgent care. Then we started rethinking the workflow. We delegated the clerical staff to approve all In Protocol refills and to delete all Duplicates. This reduced the number of prescriptions going to clinical staff or providers by 80 percent."
Further, the combined health IT has gotten things to the point where Valley Medical only needs a clerical staff member to handle 60 percent of requests.
"By automatically applying a protocol or standing order, the technology is inherently telling the staff which work they can and cannot handle and how it should be handled," said Healthfinch CEO Jonathan Baran. "In the absence of technology, all the work would need to be done manually. "
Automating has become very important to Valley Medical in three ways, Mastroberti said.
"It has improved efficiency – fewer handoffs, less scurrying through the chart, no transcription errors by the clerk," she said. "Refills are completed by noon every day, hours after arriving in the inbox. Patients are happy about this, we're getting fewer calls into the practice inquiring about the refills. Because the process is so efficient, the clerical staff is completing their refills in half the time. We now send them all of our prior authorizations."
Staff and provider satisfaction has also improved: Valley Medical is not asking clinical staff and providers to do clerical work, so it is maximizing the use of clinical staff, Mastroberti said. And Valley Medical's risk management company is happy because it is consistently refilling medications according to an established, identifiable protocol, and thus everyone is doing it the same, she added.
SAN DIEGO - Atul Gawande, MD, addressed a range of topics concerning the direction healthcare needs to move at America's Health Insurance Plans Institute & Expo Thursday.
Gawande took the AHIP stage a day after Amazon, Berkshire Hathaway and JPMorgan Chase announced that he will take the helm at their venture, an independent entity free from profit-making incentives based in Boston.
It's "the day after the venture was announced," Gawande said. "It will take on greater significance. I'm delighted that's true."
Susan Denzer, CEO of the Network for Excellence in Health Innovation at AHIP, asked about his future plans.
"At this point I can only think about this new job I'm taking on," Gawande answered. "I can only say it's a long target … over the next decade it will be a gradual progress, it won't be instant solutions."
The exact nature of the new healthcare company has yet to be announced, but Gawande confirmed that the venture will be an insurer for the million-plus employees of Amazon and partners.
"I feel incredibly lucky in this role," Gawande said. "I will get a million new patients."
While he didn't say more than that, Gawande also illuminated some of the issues healthcare is currently struggling with and said caregivers need to ask more questions of patients.
Gawande, who among his many titles as surgeon, public health researcher and author, said when he thinks about what he wants to accomplish on the writing side, he thinks about connections, "understanding the aspirations of how lives should go, and the reality."
The reality is that care, especially end-of-life care and how physicians treat serious and life-limiting illnesses does not always fulfill or align with the patient's desire for quality of life at the end of life.
Unnecessary tests and treatments waste about 30 percent of healthcare spending, and these interventions often do more harm than good. An estimated 45 percent of Medicare patients get EKGs, CT Scans, MRIs, have a stent placed or receive other procedures without good reason, Gawande said.
Physicians offer options to patients, but don't always ask what the individual wants to achieve by treatment. Doctors must be more than technicians, he said.
"The goal of the healthcare system is not survival at all costs," he said. "The goal is a good life as you define it. We've never even asked what that means."
Patients need to be asked, Gawande said, what they consider worthwhile living, what are the tradeoffs they're willing to make for more time, what is their minimum quality of life?
When Gawande asked this question of one patient, the reply was, eating chocolate ice cream and the ability to watch football.
Gawande reported his own experience with his mother at a rural hospital in Ohio where he grew up. His mother was a pediatrician; his father a surgeon. His mother had a fainting episode and the ambulance took her to the emergency room where physicians performed an ultrasound for a carotid artery.
They found nothing and put her on a helicopter to a larger hospital. At 11 p.m., laid out flat in the ER, a doctor finally asked her what exactly happened with the fainting episode. It turned out she had started on an increased dose of blood pressure medicine that morning, went for a walk and felt faint.
"She was dehydrated," Gawande said. "It took all of that to figure it out."
Another person he called the father of his friend Bruce fainted, but this individual had end stage renal disease and was on dialysis. His artery was 99 percent blocked. The physician said they needed to do surgery to clean out the artery and do a cardiac bypass operation.
"Here's a guy who's on the edge of not being independent anymore," Gawande said.
They wanted to do two procedures to address future problems.
"The benefit is in years to come. You don't need AI to determine the benefit, it's 15 years before he a sees benefit. None of it was discussed."
Bruce's father came out of surgery with a stroke, paralyzed one side of his body and was unable to speak. The man died six months later in a facility.
Bruce's dad never got the right care for a chronically ill person, said Gawande, who interviewed 200 people with serious conditions and their family members.
None had been asked what they wanted to achieve.
"It's shocking to me we've not understood it," he said. "People have priorities besides just living longer. We need to learn what their priorities are for life, we have to ask them. But we don't ask."
Where this model has been deployed, when physicians do ask, it reduces cost and actually increases life expectancy, he said.
Healthcare has the education and the science. It now needs a better delivery system.
"Precision medicine has to be matched by precision delivery," he said. "We're still in a stage of primitive thinking in how we create delivery."
After five years of work in South Carolina using this approach, physicians have reduced the death rate by 22 percent.
At Dana Farber in Boston, more than 90 percent of clinicians now ask questions of chronically ill patients months, not weeks prior to end of life.
"When we ask, what is the goal of our care, we still don't have an answer to that," he said. "What is our goal when health and independence isn't possible anymore?"
Having health insurance has been found to help the health of patients and has shown a 5 percent reduction in mortality over five years.
There cannot be exclusions for pre-existing conditions and coverage can't just be catastrophic care.
There's been enormous amount of investment in discoveries, but only now is healthcare looking at the social environment of isolation, food insecurity and the other social determinants of health.
"The genetic code is not as powerful as your zip code," Gawande said.
In Boston, when investments were made in housing rather than in shelter beds, treatment improved for chronic conditions and that, in turn, reduced costs.
"We will come to a place where we can generate scalable solutions to change the practice of medicine," Gawande said. "It's a long road. It's cleary possible."
This practical guide provides best practices for bridging the gap between the Electronic Health Records and image management systems, including guidelines into why and how imaging can be made available directly from within the EHR.
New regulations like MACRA, MIPS, and PAMA are changing the radiology landscape. Keeping your facility in line with new regulations means leveraging informatics to optimize and streamline the flow of medical imaging across radiology and beyond.
By optimizing its EHR's advanced clinical documentation technology for treating rheumatoid arthritis patients, Phoenix Children’s enhanced care and physician productivity while also saving about $1 million dollars.
Documentation for Juvenile Idiopathic Arthritis is challenging because of the complexity of this chronic relapsing disease that causes disabling joint inflammation and potential for permanent joint damage and deformity, said Vinay Vaidya, MD, vice president and chief medical information officer at Phoenix Children’s Hospital.
“When we were rolling out our ambulatory EHR four years ago, we made a focused effort to design our templates to be disease-specific,” Vaidya explained. “We ensured that the key disease measures were captured at the outset, so that this data would be easily accessible for analytics, decision support and chronic disease management.”
Staff realized the need for technology that would help clinicians capture the essential information quickly and efficiently, without too many clicks or slowing clinicians. The organization turned to vendor Medicomp because of its system allowed staff to create specific disease templates, Vaidya said.
"We’ve been able to design templates that help us track quality measures and monitor patient outcomes, yet don’t require the clinicians to spend more time documenting."
inay Vaidya, MD, Phoenix Children’s Hospital
“We’ve been able to design templates that help us track quality measures and monitor patient outcomes, yet don’t require the clinicians to spend more time documenting,” he added.
Clinical documentation is key in a robust health IT set-up. It can be accomplished in most electronic health record systems, from vendors that include Allscripts, athenahealth, Cerner, drchrono, eClinicalWorks and Epic.
Without specialty or disease-specific templates, a good portion of Phoenix Children’s clinical documentation would have to be captured manually or transcribed and stored as free text. Although technologies like natural language processing can extract clinically relevant information from free text, non-structured documentation is often missing some of the key measures required to consistently track disease and compare outcomes across institutions.
The ability to store documentation in a structured and coded format has allowed staff to use clinical data to create disease-specific dashboards. The dashboards help with chronic disease management efforts and allow clinicians to produce a longitudinal view of the patient’s disease activity. They provide at-a-glance insights regarding disease control versus disease progression, reveal what follow-up actions need to be done, and help track compliance and missed visits.
“We’re able to take the data from the dashboards and slice and dice it to answer certain specific questions, such as identifying which patients currently have inflamed joints and which don’t,” Vaidya said. “It also helps us better understand what to anticipate for patient visits and ensures that the actual visits go more smoothly for the clinicians, patients and their families.”
Before these tools, it would have been impossible to readily access much of the information clinicians now use on a daily basis to improve patient care, he added.
An additional benefit of the documentation tools is that it has improved the quality of notes, yet has not required the clinicians to spend more time documenting, Vaidya said.
“Our rheumatologists are completing 86 percent of their notes by 5 p.m. on the date of service and another 10 percent the following day,” he said. “We’ve reduced the documentation burdens for our physicians while also capturing quality measures 99 percent of the time.”
On top of all of this, Phoenix Children’s was able to save $1 million annually by virtually eliminating transcription costs in its ambulatory clinics. Clinicians can simply type in a particular disease state and the system builds 85 percent of the template for them, Vaidya explained.
“Physicians no longer dictate their chart notes,” he said.
How tech is working today
While the future of athenahealth is still unknown after the departure of CEO and co-founder Jonathan Bush, the overwhelming majority of our readers said the company shouldn’t sell to activist investors.
And while several readers commented that the time was right for a sale, of the 201 responses, 75 percent said “No,” athenahealth shouldn’t sell. Just 25 percent voted “Yes” to the company’s selling. Others suggested holding out for a better offer.
“Elliott Management is not interested in athenahealth’s vision – they are horrendous,” one observer wrote on the Healthcare IT News poll.
“I don't believe a hedge fund company is the best choice to drive the innovation that will be necessary to change healthcare,” wrote another. “I believe that their focus would be on immediate profits rather that long-term growth.”
Yet another comment suggested the company go private and continue its mission.
Others pointed to the company’s struggles over the past year, highlighting that, while Elliott Management may not be the best choice, the company does need help.
“Athenahealth caused some initial disruption, but they have been trending downward over the past 12 months, potentially reaching the ceiling of their ‘scutwork’ niche,” a reader wrote.
Bush stepped down just two weeks ago following claims of domestic abuse and sexual harassment. His departure also came amid a bid from activist investor Elliott Management for $6.5 billion. Some say the amount -- about $160 per share -- is lower than the company’s worth.
However, it’s far from being a done deal. Athenahealth's executive chairman Jeff Immelt suggested that a sale, merger or remaining independent are all options. Immelt was appointed executive chairman after Bush’s departure and is charged with sorting out the best possible course for the company going forward.
“To ensure athenahealth maximizes shareholder value and is best positioned to realize the full potential of its premier healthcare technology platform, the board has authorized a thorough evaluation of strategic alternatives, including a potential sale or merger or continuing as an independent company under new leadership,” Immelt said in a statement, earlier this month.
On June 6, Bush walked away from the company he co-founded in 1997. He was in the midst of retooling athenahealth when Elliott Management returned with an offer, about one year after they purchased a 9.2 percent stake in the company.
CORRECTION: This story was updated to reflect that athenahealth is a publicly held company.
The Pew Charitable Trusts is urging the Centers for Medicare & Medicaid Services to tackle interoperability, patient identification and limited use of standards to describe clinical information.
In a June 25 letter, Pew asserted the proposed changes to Medicare payment programs that promote interoperability would make it possible for patients and clinicians to access critical health data when and where they need it to inform care decisions.
Pew is commenting on the 2019 Hospital Inpatient Prospective Payment System, or HIPPS, a proposed rule that replaces the Meaningful Use Program with a new set of interoperability-focused measures, including several provisions designed to advance data exchange.
Ben Moscovitch, Pew’s manager of health information technology, said he believes
improvements to patient matching is a key building block for interoperability.
Also, Pew notes that the proposed changes to Medicare payment programs that promote interoperability make it easier for patients and clinicians to access critical health data when and where they need it.
But it’s not always easy.
HIMSS, CHIME, AHIMA and ONC have tackled the slippery interoperability conundrum, and some advances have been made over the years.
CMS’ efforts to promote interoperability through hospital payment programs face three key barriers, according to Pew.
It’s often difficult to match health records to the patient. Moreover, it’s not easy to extract useful data from health records. Also, the standard way to describe clinical information is often imperfect.
As Pew sees it, improvements to patient matching is a critical building block for interoperability.
Yet, researchers have found match rates as low as 50 percent to link records held in different healthcare facilities. So, healthcare providers lose the ability to access critical data to inform care decisions.
It’s tricky. Researchers point to match rates as low as 50 percent when they tried to link records from different healthcare facilities. As a result, this challenge in correctly linking an individual with his or her records impedes patients’ and healthcare providers’ ability to access critical data to inform care decisions.
CMS continues to emphasize the utility of health insurance claims for research, the agency should support efforts to ensure the data include critical information – namely the brand and model of implanted medical devices.
Pew is juggling several initiatives focused on improving the quality and safety of patient care, facilitating the development of new medical products and reducing costs.
In addition to championing better patient matching, Pew proposes the use of simple and transparent APIs. It also calls for standardized clinical terminologies.
The U.S. Department of Veterans Affairs’ EHR project will go live in the Pacific Northwest and by fully functional by March 2020, VA officials told the House Committee on Veterans Affairs on Tuesday.
The VA will ensure the effectiveness of its pilot sites early in the process, assessing the planned sites in Spokane, Seattle and Medical Lake, Washington in July, September and August, said Acting VA Secretary Peter O’Rourke.
In October, the VA will begin the EHR deployment to those sites.
But Committee Chairman Rep. Phil Roe, R-Tennessee, weighed in on the scope of the project, outlining concerns about the cost and significance of getting the project right.
“$15.8 billion over 10 years, including $10 billion to Cerner, is a staggering number for an enormous government agency,” said Roe. “The EHR modernization effort is not just a technology project. It will have a major impact on how the Veterans Health Administration operates.”
“That means clinical and administrative workflows,” he said. “It also changes the culture, as VistA has.”
The EHR modernization project has been a long road already. Former VA Secretary David Shulkin, MD made the decision to sign with Cerner in June 2017. But the contract wasn’t signed until May 2018 -- after a year of staffing changes, interoperability issues and concerns about aligning the project to match the Department of Defense as that project has hit its own technical issues.
Rep. Tim Walz, D-Minnesota shared those concerns and added that oversight and leadership will be crucial throughout the entirety of the project.
“There are going to need to be eyes on this all the way,” said Walz. “The Government Accountability Office should be in attendance at every single governing board member…. GAO must have direct and frequent access to VA, Cerner, and program management support contractors.”
Walz also wants the VA to provide the GAO with quarterly progress reports.
VA and DoD have been working closer than in previous attempts to align the EHRs. The idea is to take the lessons DoD has discovered during its own Cerner implementation -- MHS Genesis -- so that the VA can have a more seamless transition from its legacy VistA EHR to Cerner.
DoD and VA have already found areas where the two agencies can work closely together and share resources, while aligning DoD and VA EHR deployments especially at joint agency sites, explained Defense Health Agency Director Vice Admiral Raquel Bono.
Roe also formally announced the development of an oversight subcommittee that will oversee the EHR implementation to help with this process. And O’Rourke said the agency has set up five programmatic, technical and functional teams to support the project.
Those groups include a legacy EHR Modernization pivot workgroup, steering committee, governance integration board, a functional governance board and a technical governance board.
Walz expressed support of these groups to manage the project, but railed on the VA officials over the continued lack of permanent leadership.
“We still don’t have a confirmed secretary, deputy secretary, undersecretary for health, or chief information officer: Pretty important those positions be filled with some stability,” said Walz.
Rep. Jim Banks, R-Indiana reiterated that point, referencing a Politico report that claimed Genevieve Morris, Department of Health and Human Services principal deputy coordinator of health IT would lead the EHR project: “If that’s true, when was the decision made, and why isn’t she testifying today?”
While O’Rourke called her a candidate, stating she’s “perfectly qualified,” he didn’t confirm those reports.
Indeed, VA leadership has seen an incredible amount of turnover in the last six months. Following negative reports on Shulkin, his Chief of Staff Vivieca Wright Simpson retired. President Donald Trump fired Shulkin shortly after, which began a long line of turnover.
But O’Rourke said he was confident in the agency’s EHR plan, as they’re working closely with DOD.
“We’re listening to advice from respected leaders in healthcare,” he said. “We’re fully engaged with Cerner regarding all critical activities: establishing governance boards, conducting current state reviews, and optimizing the deployment strategy.”
Interoperability is the ultimate goal of healthcare information systems. Software and cloud-based services need to be able to talk to one another, to exchange clinical and administrative data to enable complete access to a patient’s record and help clinicians deliver the best possible care.
But health IT vendors and healthcare provider organizations still have a long way to go when it comes to attaining interoperability. In the years ahead, though, progress will be made and there will be various next-generation tactics and techniques that help advance this goal.
For one, artificial intelligence will assist interaction with data to push interoperability forward, said Jitin Asnanni, executive director of the CommonWell Health Alliance, a trade association of health IT companies working to create nationwide access to data.
“As exchange enters the mainstream, broad sets of data become more liquid, and an increasing array of end-users start depending on that data, for example, apps specializing in the sub-components of population health, public health, precision medicine, etc.,” Asnanni said. “End users are going to struggle with the signal-to-noise ratio – even when the data itself is intelligently indexed.”
Intelligent assistants will become requisite features in the tools that to engage with the data, helping to sort through the data and unearth the critical pieces of information, analogous to voice assistants like Siri, Alexa or OK Google, he added.
Don Woodlock, vice president of HealthShare at InterSystems, which specializes in health information interchange, said creating a unified health record is the next big focus.
"Healthcare leaders need to make it a priority to implement an interoperability solution that brings different data elements together to create a unified health record that can be shared across the care continuum."
Don Woodlock, HealthShare at InterSystems
“We live in a multi-health world – multiple data sources, multiple providers, multiple patients in a population, and multi-time as you support a patient through their lifetime,” he explained. “The best way to survive and thrive in this very complex world is to empower everyone with a unified health record, be it caregivers, patients, families, physicians, data scientists, case managers and even AI algorithms.”
If a provider organization wants to succeed in value-based care, for example, it needs real-time access to all patient information, Woodlock said. This includes everything from patient data to population and insurance claims data.
“To make unified health records a reality, interoperability technology must be able to combine multiple data types, from structured data such as weight and height to unstructured data in the form of handwritten clinical notes, into a single snapshot of the patient,” he said. “Healthcare leaders need to make it a priority to implement an interoperability solution that brings different data elements together to create a unified health record that can be shared across the care continuum.”
Moving forward, one of the biggest drivers of interoperability technology will be the FHIR standard. Over the past few decades, the number of data sources and the volume of patient data have increased exponentially. Interoperability used to mean just connecting two systems together, but today’s healthcare ecosystem is much more complex.
“In order to consistently deliver high-quality care, provider organizations need real-time access to multiple health information systems to obtain a comprehensive, longitudinal view of their patients’ health history,” Woodlock said. “FHIR is the only standard that enables seamless and real-time data sharing, making it critical for CIOs to ensure that every health information source adheres to the standard.”
Raychelle Fernandez, vice president of Dynamic Health IT, whose products focus on the quality and interoperability of 2015 Edition Health IT Certification Criteria and integrate with EHRs, agreed with Woodlock that the FHIR standard will play a big role in next-generation interoperability.
"Patients also are taking a measured interest in personal health trackers. As a consequence, we’ll see more devices that ‘phone home’ and integrate with portals and personal health record applications."
Raychelle Fernandez, Dynamic Health IT
“In the near term, the involvement of heavy hitters like Amazon, Apple, Google and Microsoft will spur innovation, but so too will smaller startups that are able to bring fresh ideas to areas with relatively low barriers of entry; think FHIR, blockchain or open source data analytics,” Fernandez said. “We foresee growth in patient-centered health applications. This will involve FHIR integrations through API hooks already existing in 2015 Edition-certified Health IT.”
At first, this likely will happen one health system at a time – as with Apple’s foray into bringing PHI to the iPhone – by getting major provider networks on board gradually, she added. API integrations will allow patients to begin consolidating access to their data across disparate providers, she said.
“Patients also are taking a measured interest in personal health trackers, while providers are finding ways to manage population health remotely and health insurers are mandating feedback from medical devices such as CPAP machines,” Fernandez added. “As a consequence, we’ll see more devices that ‘phone home’ and integrate with portals and personal health record applications.”
Another next-generation move for interoperability will involve natural language processing technology, said Tim Kowalski, president and CEO of Halfpenny Technologies, a vendor of healthcare interoperability systems for clinical data exchange.
“The need for both structured and unstructured medical records data is driven by several factors,” he said. “Key among them is using the information in unstructured data to fill gaps in the structured data. Natural language processing is an important next-generation feature. NLP exposes data needed by analytics platforms to identify patients at risk and can efficiently direct care managers to observations and conditions that may otherwise be masked in the narrative of unstructured data.”
The ability to analyze and extract meaning from unstructured data sources such as progress notes and history will contribute greatly to advancements in care coordination.
“NLP systems that can learn from review feedback offer the most promise to impact care coordination,” Kowalski said. “Systems that involve significant manual attention will not be able to keep pace with the demands of risk-sharing models.”
The growth in the amount of data to be managed in healthcare shows no signs of slowing. Records of patient encounters are just the tip of the iceberg.
The increased use of connected digital medical devices and health information exchanges (HIE) means that healthcare providers are collecting, storing, and sharing more data than ever in their electronic health records (EHRs). On top of that, analytics programs, which are still in their early stages, are now generating a continuous stream of reports that need to be shared across health systems. And coming soon will be the need to store genomic data as precision medicine uncovers new treatments.
The challenges posed by this growth of data and the need to support collaborate teams is part of the appeal for migrating the EHR and other IT functions to a cloud.
There’s no specific blueprint for an EHR cloud migration. But an important first step is to define the strategic business and operational goals. Your organization will be in a better position to choose the right cloud model, the right cloud provider, and the right migration path if you identify the benefits you want to gain from a cloud-based
The obvious benefits to providers of a cloud deployment are faster and easier access to data by clinicians, reduced IT and capital costs, better data backup and disaster recovery (DR), greater storage capacity, and a powerful and scalable platform for analyzing data.
In a 2016 HIMSS Analytics survey, increased performance and reliability was the top reason cited by healthcare IT executives for a cloud migration, followed by ease of management, total cost of ownership (TCO), and infrastructure agility.
These and other reasons to adopt a cloud solution (such as speed of deployment and lack of internal staff/expertise) are not mutually exclusive, of course. Providers interested in lower TCO will also want to keep IT staff costs down. Those seeking improved performance and reliability likely will be interested in infrastructure agility, speed of deployment, and business continuity.
A key element in devising a strategy for an EHR cloud migration is conducting a network bandwidth assessment. The continuous transmission of data and services to and from an off-site cloud facility can easily exceed the capacity of the existing network infrastructure. This in turn could lead to data accessibility and network performance problems during peak usage hours, offsetting the expected clinical and operational benefits of a cloud-based EHR.
Security and Privacy
A major strategic consideration for healthcare providers when planning an EHR migration to the cloud is the security of protected health information (PHI). Under HIPAA (the Health Insurance Portability and Accountability Act), information created, stored, or shared by “covered entities” in the course of must be protected in order to shield the identity of patients.
Information protected under HIPAA includes a patient’s name, Social Security number, date of birth, contact information, health insurance identification numbers, diagnoses, courses of treatment, medications, and billing details. Failure to protect PHI under HIPAA requirements can be costly: Fines range from $100 to $50,000 per violation, with an annual maximum of $1.5 million. (Criminal penalties also are possible under HIPAA.)
A number of hospitals and other healthcare providers have paid seven-figure fines for HIPAA violations, including Oregon Health & Science University, which paid $2.7 million to settle a pair of HIPAA violations in 2013, one of which involved patient information stored in a Google-based cloud system for which the health system lacked a contract.
HIPAA also requires covered entities and business associates to “conduct risk analyses to identify and assess potential threats and vulnerabilities to the confidentiality, integrity, and availability of all ePHI they create, receive, maintain, or transmit,” the U.S. Department of Health and Human Services (HHS) explains.
In addition to protecting patient privacy under HIPAA, healthcare providers considering an EHR cloud migration must determine how data stored with a cloud services provider (CSP) should be secured. Specifically, provider organizations need to decide how much control over healthcare data, applications, and processes they are willing to cede to a CSP.
However, even if a contract gives a CSP high levels of control over PHIs, applications, and processes, healthcare providers bear responsibility for protecting data and meeting compliance requirements. “Healthcare entities must stay informed of where and how electronic protected health information (ePHI) is moved, handled, or stored by their CSP,” advises the Cloud Standards Customer Council. “For example, if a CSP moves data to another country, it may be subject to international laws and therefore non-compliant with government regulations.”
HIMSS established a Cloud Computing Work Group to provide guidance on creating an acceptable use policy (AUP) for an organization as it moves applications and communications to the cloud. The template is available for download from HIMSS.org
Private, public and hybrid
The most fundamental decision providers must make is choosing a cloud computing model – public, private, or some hybrid. A 2016 HIMSS survey shows that private clouds comprise roughly three-quarters of healthcare provider cloud deployments (74 percent), nearly three times the number of public cloud deployments (26 percent).
This doesn’t mean healthcare organizations must choose one or the other; they might opt to employ a hybrid model, mixing public and private platforms. The HIMSS survey reveals that healthcare providers typically have at least three different CSP vendors, while most employ a combination of private and public clouds.
A number of factors can influence a provider’s choice of cloud computing models, including security and accessibility issues, pricing, performance levels, and more. These requirements can vary depending on the workloads being migrated to the cloud, which explains why most providers use a mix of public and private clouds and more than one CSP.
Advice on how to take a step-by-step transition with cloud computing platforms
John Houston, UPMC vice president of security and privacy and associate counsel at shares his experience with cloud vendors and how he approaches questions of uptime reliability and security. He spoke at the Healthcare Security Forum in September 2017.
Finding the Right EHR vendor
While an experienced healthcare CSP can offer useful advice regarding cloud migration strategies and goals, it is important that provider organizations develop a clear picture of their EHR migration objectives before choosing a CSP. This will make the vendor selection process faster and reduce the odds of healthcare providers choosing a CSP whose services and contract terms are misaligned with their needs.
Once a healthcare provider has determined the strategic goals of an electronic health records (EHR) migration to the cloud, IT and business decision-makers can begin making choices about cloud models, cloud services vendors and migration plans.
This doesn’t mean healthcare organizations must choose one or the other; they might opt to use multiple vendors and multiple cloud computing models. The HIMSS survey reveals that healthcare providers typically have at least three different CSP vendors, while most employ a combination of private and public clouds.
A number of factors can influence a provider’s choice of cloud computing models, including security and accessibility issues, pricing, performance levels, and more. These requirements can vary depending on the workloads being migrated to the cloud, which explains why most providers use a mix of public and private clouds and more than one CSP.
The U.S. Department of Veterans Affairs spent about $3 billion from 2015 to 2017, an average of $1 billion a year, to support its legacy EHR VistA, according a new Government Accountability Office report.
According to officials, the costs covered the EHR platform, interoperability efforts and a Virtual Lifetime Electronic Record Health, supporting functions like networks and infrastructure, development, operation and maintenance.
VA analyzed its obligations for supporting VistA to assess these costs, which included data standardization and data sharing between the VA, the private sector and the Department of Defense, the report found.
DoD and VA have been working for years to interoperate. But VistA is more than 30 years old, costly to maintain and doesn’t support interoperability, officials said.
Some of these results were shared during Tuesday’s VA House Committee meeting, where VA officials announced the first Cerner install will go live in 2020. During that hearing, Chairman Rep. Phil Roe, MD, R-Tennessee expressed concern over the “staggering” cost of the project.
The implementation is projected at $16 billion over the next 10 years, with $5.8 billion of those funds set aside to manage and support the current VistA infrastructure. But GAO Director of IT Management Issues David Powner said the estimate is low, as the VA failed to include internal employee costs.
Roe added that the speed at which technology is changing will add additional new costs and the EHR platform that rolls out in 2020 will look “totally different in 2028.”
“I don’t see how there couldn’t be more costs,” said Roe.
Adding to these costs issues, according to the report, is “there is no single information source that fully defines the scope of VistA.” Instead, the existing system definitions and its components are identified by multiple sources, describing the system from varying perspectives.
This includes modules and associated business functions, systems and interfaces and documentation -- among others, according the report. But there is no complete definition of the platform, due to variances in VistA between its health facilities.
In order to prepare for the Cerner project, the VA has taken steps to analyze, assess and plan for the new EHR. Officials are also attempting to standardize VistA across its sites, clarifying the VA’s approach to interoperability, establishing governance for the new IT project and preparing the initial project launch.
If the U.S. Senate confirms Robert Wilkie as Department of Veterans Affairs Secretary, implementation of the near-$16 billion Cerner electronic health record would be a top priority at the agency, Wilkie said on Wednesday during his confirmation hearing.
“[The new EHR system] modernizes our appointment system, it is also the template to get us started on the road to automate disability claims and our payment claims, particularly to our providers in rural America and those who administer emergency care,” Wilkie said.
More importantly, the Cerner system will bolster interoperability, he added. The system will be able to connect with the Department of Defense and private sector actors, such as pharmacies, to “create a continuum of care” and help prevent suicide and opioid abuse.
The plan is to create a unified EHR with the DoD through the Cerner platform, while aligning the rollout with the DoD’s scheduled implementations to achieve efficiencies, said Wilkie.
But Sen. Patty Murray, D-Washington, who blasted the DoD in April for “putting patient lives at risk” with its initial rollout, told Wilkie she was concerned the VA was still pushing forward with the contract despite the DoD’s challenges.
“You signed the contract to move forward on procuring the same system” as the DoD, said Murray. “We can’t see the same problems that DoD has experienced. So, I want to know what you will do to oversee the rollout and what specific steps you’re going to take to make sure quality and access to care is not diminished.”
Healthcare remained a key discussion point throughout the hearing, with Wilkie pointing out four areas where the VA needs to improve: culture and communal aspects, care access, agency backlog and human resources business.
If confirmed, Wilkie will fill the role left vacant by David Shulkin, MD, who was fired by President Trump on Twitter in March. Shulkin made the initial push to transition the VA’s legacy system to Cerner in June 2017.
“There is overwhelming opposition to the privatization of the VA from all of the major veterans organizations,” said Sanders. “Do you believe in the privatization of the VA?”
“No, sir, I don’t,” said Wilkie.
“Will you vigorously oppose, whether it is the Koch brothers and their various organizations or the President of the U.S., any effort to privatize the VA?” Sanders asked.
“My commitment to you is that I will oppose efforts to privatize the VA," Wilkie said.
If confirmed, Wilkie will be charged with leading the recently passed MISSION Act, which reformed the Veterans Choice program and lets veterans seek private sector care if there are long wait times in their area or if they live a certain distance from a VA medical facility.
Wilkie stressed that VA is central to veterans healthcare and that the Choice program is designed to support VA care, while removing barriers for veterans who seek private sector care.
“Many of the issues I encountered as acting secretary were not with the quality of care but were getting veterans through the door to get that care," Wilkie said.
Healthcare information technology is evolving in many ways, and quickly so. That means health IT consulting has to change with the times, to evolve alongside the technology consultants help healthcare provider organizations master.
Consultants from top firms across the health IT consulting spectrum have various ideas on what firms must do next to successfully aid provider organizations with technology. Call them next-generation health IT consulting goals.
For example, health IT consultants must move beyond prediction, said Jeff Geppert, a senior research leader at Battelle, an independent research, consulting and development organization that applies science, technology and engineering to challenges in various industries, including healthcare.
“The current narrative on health IT consulting services is becoming commonplace,” he said. “The focus is on data science and applications that leverage large and connected datasets, powered by predictive analytics and artificial intelligence/machine learning running in the cloud.”
However, there is nothing very transformative about prediction, he cautioned.
“It is by necessity short-term and event-driven,” he said. “Healthcare provider organization CIOs should be looking for health IT consultants with a compelling long-term and goal-driven vision, and a plan to work with them to bring that vision about.”
Geppert also focuses on a concept he dubs “the new Model T.”
"The focus [of health IT consulting] will shift to extracting more value from investments and identifying which new investments are necessary to drive competitive advantage for the system."
Jeff Curin, Burwood Group
“Health IT consulting today seems like the auto industry a hundred years ago with multiple companies competing to build the most technologically advanced car,” he said. “Somewhere out there is the Henry Ford of health IT who will build something inexpensive, standardized, aligned with the needs of people, and scalable from individuals to the federal government.”
Healthcare provider organization CIOs should be looking to partner with health IT consultants with demonstrated longevity across multiple industries, he added.
John Curin, vice president of innovation at Burwood Group, a healthcare consulting firm that focuses on direct acute care, physician workflow and health IT, said he sees healthcare CIOs watching consulting services expanding beyond the EHR.
“The vast majority of the health IT consulting space has been overwhelmingly EHR-centric up to this point,” he contended. “Today, EHR and revenue cycle systems migration is largely complete or well-understood. The focus will shift to extracting more value from those investments and identifying which new investments are necessary to drive competitive advantage for the system.”
Further, consultants will offer services to help healthcare providers transition – the shift will be toward internally developed interdisciplinary strategies with a focus on systemwide financial and clinical outcomes improvement, Curin said.
“For example, to make IT more successful, CIOs will stop reacting to external plans and timelines, such as regulatory compliance introduced by meaningful use or vendor roadmaps based on product lifecycle and implementation schedules,” he said. “Instead, they will start building frameworks to drive better financial and clinical performance.”
"The time is now for CIOs to embrace consumerism and create a digital strategy that becomes a competitive advantage"
Rob Barras, CTG Health Solutions
On another note, consumerism is significantly affecting healthcare today, forcing healthcare provider organizations to meet changing patient expectations. Along with receiving the best medical care available, today’s healthcare consumers also expect a first class experience across every touchpoint at an organization.
“With expectations becoming increasingly ‘consumerized,’ executives are realizing that their healthcare organization will be judged on how patients rate their overall experience,” said Rob Barras, executive leader, health solutions, at CTG Health Solutions, a clinical and financial IT consulting firm that serves healthcare provider, payer and life science organizations. “This means that meeting these demands needs to be front of mind for CIOs.”
This trend toward a consumerism approach will accelerate significantly, and health IT consultants will have to be on top of it to successfully assist healthcare provider organizations, Barras said. Soon, Amazon, Wal-Mart, CVS and Apple will consider themselves care providers, he added. And while most traditional health systems are doing business as usual, smart CIOs will plan ahead to match the future expectations set by these retail giants in yet another industry, he said.
“Many of these major players believe there is an opportunity to capitalize on what they believe traditional providers have been slow to do – provide easy access and quality care at a reasonable and transparent price,” he said. “The time is now for CIOs to embrace consumerism and create a digital strategy that becomes a competitive advantage, and for consulting firms to rush to assist with this stage in the planning process.”
And Barras said that moving forward, health IT consultants have to be getting healthcare provider organizations implementing the latest healthcare information technologies now, not later.
“For the past couple of years, many healthcare organizations have treated emerging technologies as somewhat of a luxury and not as something with immediate business value,” he said. “However, technologies have matured quickly and already are being implemented to meet business needs, meaning organizations without structured plans to roll out the latest in analytic, AI and IoT solutions are in danger of falling out of step with competitors.”
This means that health IT consultants must focus on becoming innovation hubs – as opposed to internal caretakers – of technology to provide true value to healthcare clients, Barras added.
“The right CIO can help change the mindset of an organization, but that change must be supported from the top down,” he advised. “A key to this is working with consulting partners who understand that using technology is a way to create competitive advantage for the future. Providers should engage partners who can clearly articulate the value of their work and the vision.”
What tech is shaping the future of healthcare IT?