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Articles on this Page
- 07/17/18--13:59: _Health Catalyst lau...
- 07/18/18--05:56: _IDC and Gartner on ...
- 07/18/18--06:48: _Health Wizz pilots ...
- 07/18/18--10:12: _CMS head Seema Verm...
- 07/18/18--13:30: _Centegra takes HIPA...
- 07/19/18--06:31: _EHRs can improve pa...
- 07/19/18--09:43: _Human factors need ...
- 07/19/18--14:13: _Cass Regional EHR b...
- 07/20/18--10:07: _More than half of M...
- 07/20/18--13:46: _Top 3 CIO prioritie...
- 07/23/18--07:15: _Simplifying Healthc...
- 07/23/18--07:20: _Next-gen precision ...
- 07/23/18--12:32: _NHS to bolster hosp...
- 07/24/18--07:42: _Senate confirms Rob...
- 07/24/18--13:04: _Mount Sinai opens b...
- 07/25/18--06:26: _How an academic med...
- 07/25/18--07:02: _A CIO's take on EHR...
- 07/25/18--09:22: _EHR interoperabilit...
- 07/25/18--11:33: _DoD raises budget o...
- 07/27/18--11:51: _Texas Hospital Asso...
- 07/17/18--13:59: Health Catalyst launches new hospital safety surveillance analytics
- 07/18/18--05:56: IDC and Gartner on blockchain: What CIOs should be doing now
- 07/18/18--06:48: Health Wizz pilots blockchain and FHIR mobile app for EHRs
- 07/19/18--06:31: EHRs can improve patient safety - if they're optimized well
- 07/20/18--10:07: More than half of Maine prescribers are now EPCS-enabled
- 07/23/18--07:15: Simplifying Healthcare Data Management
- 07/23/18--12:32: NHS to bolster hospital IT with $540 million in new spending
- 07/24/18--13:04: Mount Sinai opens biomedical blockchain research center
- 07/25/18--09:22: EHR interoperability: We're closing in on a signature moment
Health Catalyst announced a new surveillance module for its Patient Safety Monitor suite that aims to help hospitals protect patient safety by deploying predictive analytics to monitor, predict and prevent inpatient risk.
Built atop the Health Catalyst Data Operating System, the new module was developed over two years of intensive and expensive research – nearly $50 million, the company said. It's a trigger-based surveillance system, incorporating predictive algorithms and artificial intelligence, that can spot patterns of harm and offer decision support to address potential hazards.
By combining text analytics and near real-time data from multiple sources, the technology can detect safety risk for inpatients.
Health Catalyst noted that the standard approach of manual reporting of hospital safety events, often using data that is at least 30 days old, reportedly finds less than 5 percent of all-cause harm.
Meanwhile many electronic health records and data warehouses have drawbacks of their own, missing the AI capabilities that could enable wider surveillance. Many hospitals, therefore, are limited in their approach to patient safety, using point solutions focused on specific risks, rather than whole-person safety.
As part of its patient safety efforts, Health Catalyst has applied for certification as a Patient Safety Organization with the Agency for Healthcare Research and Quality. If approved, the Health Catalyst PSO will offer an environment where hospital clients can collect and analyze patient safety events from their EHRs to learn and improve, the company said.
The surveillance technology release comes on the heels of Health Catalyst completing the acquisition of Medicity from Aetna to expand its footprint in the outpatient space and combine analytics with HIE. The merger increases its customer based to now include 75 health systems with more than 1,000 hospitals and 185,000-plus ambulatory sites.
In an interview, Health Catalyst CEO Dan Burton said the company will leverage Medicity’s data sets and transactional capabilities to complement its own analytics tools and help its clients maker smarter, data-driven decisions to enable value-based care.
"We've amassed a big data set focused more on the acute care setting, which is were we grew up, whereas Medicity has strong transactional capabilities that are really a complement to our analytics space capabilities, and they're more ambulatory focused," Burton said.
By adding Medicity's technology, Health Catalyst expands its reach, bringing real-time analytics right to the workflow inpatient and outpatient EHRs, he said.
"Clinically integrated networks and others have rightly noted a gap in Health Catalyst's experience set with real-time transactional capabilities," said Burton. "Offering that data exchange capability, in-depth, is not something we've had a great answer for."
Blockchain. Health IT professionals know about the distributed ledger technology so full of promise for boosting EHRs, enabling interoperability, data cybersecurity and streamlining the supply chain.
Those are just three of the oft-cited use cases. Myriad others have already emerged, and more are surfacing while technologists and IT executives sort the hype from reality.
The overarching question, in the meantime is: What will it take for blockchain to gain a wider foothold in healthcare?
What IDC, Gartner advise CIOs to know about blockchain
IDC on Tuesday published a new report “Blockchain in Health IT Interoperability,” while tech consultant Gartner last week updated an advisory geared toward chief information officers spanning multiple vertical industries.
Gartner research published in July 2018 projected that companies worldwide, not just healthcare, will invest some $360 billion by 2026 on the way to a major spending surge that surpasses $3 trillion by 2030.
Gartner added that blockchain is not straightforward and, instead, will force hospitals to embrace decentralization within existing business models and processes -- which is going to be a high hurdle given that only one percent of CIOs responding to the Gartner Survey have adopted blockchain and a mere 8 percent are in pilot or short-term executions stages while 77 percent currently have action planned.
“CIOs can (and should) now to begin considering blockchain without the risk of being left behind,” Gartner wrote in its advisory. “Hype Cycles are not indicating obsolescence. Re-engineering businesses to the extent that blockchain envisages will take time, but that doesn’t mean it won’t happen and the extent of that change on businesses, industries and society will be enormous.
To that end, IDC made recommendations for employing blockchain.
First and foremost, weigh the pros and cons of blockchain interoperability and make informed decisions, the firm said. It’s critical to give some thought to how decentralized, distributed and immutable properties might help stakeholders achieve their goals.
IDC also suggested that hospitals press for blockchain interoperability with providers and patients, and to coordinate tasks, such as reconciling data and gathering records from various sources. It’s important to adopt blockchain interoperability early to take advantage of low-hanging fruit.
And if publicly-driven blockchain interoperability seems too much of a risk, consider going private.
Blockchain interoperability and beyond
Blockchain technologies also offer an opportunity to unleash untapped value and logic from relatively stagnant and siloed data reserves.
IDC, for instance, noted that by 2020, 20 percent of healthcare organizations will have moved beyond pilot projects and will be using blockchain routinely for operations management and patient identity.
Moving forward, blockchain contributes to reshaping healthcare interoperability by serving as a next-generation middleware that couples health data with decentralized, distributed and immutable qualities, IDC said. With the advent of FHIR and open APIs, blockchain could provide a lattice to accelerate clinical data distribution.
Blockchain "could solve the challenge health systems have when their datasets get mismatched, or the problem of duplicate records," said StClaire. For one thing, under the current system, there are "20 different ways you can enter date-of-birth. Not a really great approach."
Experts say blockchain could solve the challenge health systems have when their datasets get mismatched, or the problem of duplicate records. Others suggest blockchain could help processing and adjudication of claims, noting that 6 percent of all claims are denied because of incomplete or incorrect information. The list of use cases also includes a master patient index, clinical trials, supply chain and more.
Whether blockchain will truly empower the industry with new ways of achieving interoperability or ultimately land in the buzz trash bin -- well that, of course, remains to be seen.
Gartner’s updated advisory, however, carried this ominous caution: “CIOs ignore the trend at their peril.”
Health Wizz has updated and is piloting its unusual blockchain- and FHIR-enabled EHR aggregator mobile app, which uses blockchain to tokenize data, enabling patients to securely aggregate, organize, share, donate and/or trade their medical records. The idea is to enable individuals to control their health data as easily as they do their online bank accounts to allow better communication between healthcare organizations and caregivers to pave the way for a higher standard of care.
"There are many new features on the platform meant to foster user engagement and social connectivity," said Health Wizz CEO Raj Sharma. "The social aspects of the app usher in a new era of digital health where users create and become part of their social 'health network.'"
Users now can earn "health tokens," called OmPoints, and get rewarded for staying healthy. Users will be able to redeem accumulated OmPoints for tangible items such as Amazon gift codes or other gift cards. And participants can create their own health-oriented campaigns and challenges and invite their friends, family and colleagues to participate in these campaigns and challenges, for instance.
Also new, institutions such as hospitals and pharmaceutical companies can fund health-related campaigns or research and create cohorts and invite them to participate. Using the Campaign Wizz Bridge Application Dashboard, they can reward participants with OmPoints for taking part in clinical trials or for adopting a healthy lifestyle.
"This is especially important for patients and medical institutions who are living with and managing a chronic disorder," Sharma said. "Our partnership with Cape Fear Valley Hospital involves a jointly launched chronic disease management pilot program, where participants are Medicare beneficiaries with congestive heart failure. Our goal is to reduce hospital readmission in the first 30 days of discharge and improve outpatient care."
With the pilot program at Fayetteville, N.C.-based Cape Fear Valley Hospital, it's not about what the vendor is trying to prove but rather what it is trying to solve, Sharma said.
"[Patient] data always remains with the user. Processing is done via smart contracts, which are open and immutable processing paths that can be scrutinized and audited."
Raj Sharma, Health Wizz
Cape Fear Valley Health CEO Michael Nagowski added that since eighty-six cents of every dollar spent on healthcare goes to treating or managing a chronic condition, blockchain "technology tools help to reduce inefficiencies and improve the ability to proactively identify risks and coordinate care, enabling to better treat and manage chronic diseases.”
The exchange and transfer of OmPoints are both happening on the blockchain on the new platform without the need for users to learn new technology, he added. In fact, users will not even be aware they are using blockchain to manage rewards points in their digital wallets, he said.
"Blockchain, without a doubt, is one of the most innovative technologies since the Internet," Sharma said. "It has multiple applications. Finance systems, for example, leverage distributed ledger capabilities of the blockchain. Health Wizz is leveraging the smart contract capabilities of Ethereum blockchain to deliver rich data-sharing experiences. We will also leverage the immutability features of blockchain to verify the provenance of user data."
The important thing for users of the Health Wizz platform to remember, Sharma said, is that user data will always be completely under their control. Users will have the tools to configure data bundles of their choice and enter into sharing contracts of their own will, in anonymity or pseudonymity mode.
"The key to that particular transaction governed by contracts will be stored on the blockchain," he explained. "Once again, the personal medical data is not on the blockchain. The data always remains with the user. Processing is done via smart contracts, which are open and immutable processing paths that can be scrutinized and audited."
In addition, the use of smart contracts and blockchain enables Health Wizz to create a marketplace where health data can be exchanged in a peer-to-peer manner without the need for data brokers.
Health Wizz implements the FHIR HL7 standard to access data in a standardized manner – both on the data production side and the data consumption side. For the former, when a hospital or practice EHR allows users to access their medical records using a FHIR interface, the Health Wizz application enables users to leverage this interface to download their medical records on their mobile device.
Starting January 1, 2019, CMS will require healthcare organizations to provide view/download/transmit capability for users' medical records using a standardized interface such as FHIR.
"Some provider institutions have already started providing this capability," Sharma said. "Even if the health data was acquired in a different format, for instance, if the user took a picture of an old paper record, the Health Wizz app processes this data and makes it accessible on a user's mobile device using a FHIR interface."
On the data consumption side, when institutions such as pharmaceutical companies and medical research organizations want to access clinical and genetic data residing on a user's mobile device, they can also do this using the FHIR interface in the Campaign Wizz Bridge Application.
"This use case aims to reduce readmission rates for patients who are being treated for chronic conditions," he said. "At Cape Fear Valley Hospital, we are striving to get patients engaged in their health journey by using the Health Wizz app so they can interact with clinicians virtually instead of the hospital sending paramedics to patients' homes."
Patients, for instance, earn OmPoints which they can spend on tangible items such as Amazon gift codes while improving their health while hospitals like Cape Fear can ultimately hospital reduce readmissions.
The Centers for Medicare and Medicaid Services on Wednesday called for documentation of E/M visits to be scaled back.
The move follows last week’s proposed rule that would bring sweeping policy changes and a dramatic reduction in the documentation CMS would require of physicians.
In line with its Patients over Paperwork initiative, the new effort would streamline coding for evaluation and management visits. Existing E/M documentation guidelines – first developed nearly 25 years ago – too often nowadays lead to physicians cutting and pasting of large chunks of text across electronic health records, strictly for billing purposes, said CMS Administrator Seema Verma on Wednesday.
— Administrator Seema Verma (@SeemaCMS) July 18, 2018
"This is a poor use of their time," Verma said during a call with reporters. "We are not leveraging the value of American clinicians."
So, as part of the 2019 Physician Fee Schedule Proposed Rule, CMS has called for documentation of E/M visits to be scaled back. The rules call for "new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services," according to the proposed fee schedule.
They would also: allow practitioners to choose how they document office/outpatient E/M visits; let them "use time as the governing factor" in selecting the visit level they choose; enable docs to "focus their documentation on what has changed since the last visit or pertinent items that have not changed, rather than re-documenting information," and also "allow practitioners to simply review and verify certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it."
All told, those relaxed rules could save U.S. providers more than 50 hours per clinician per year, said Verma. Add it up across all physicians nationwide and that's "500 years of additional time for patient care," she said.
By moving to a system with a single payment rate, collapsing the codes between level 2 and 5, CMS is allowing the doctor to "focus on what is most important for the patient in front of them," said CMS Chief Medical Officer Kate Goodrich, MD.
A boon for EHR usability, patient safety, pop health analytics?
Beyond the promise of removing redundancies and jettisoning superfluous requirements, the new rules could have big implications for the efficiency and efficacy of health information technology, said National Coordinator Don Rucker, MD.
Noting that the E/M documentation rules were first put together way back in 1995, and that they now require a lot of needless "medical school-type text" shuffled around EHRs in "big, templated notes," Rucker said it was time for a new approach.
"It may not have made sense then, but in an era of electronic health records, we've heard from everyone that it just doesn't make sense."
The drawbacks and even dangers of note bloat are obvious and long-documented. Trying to sort through and find relevant clinical information in non-templated data is very hard, he said, and there are real patient safety issues when important data is "buried in boilerplate."
There are other big disadvantages too, Rucker said, affecting everyone from med students ("it has distorted our education system for medical trainees") to patient (the "see the doctor looking at the computer and not at them") to the U.S. taxpayer (all this documentation requires armies of coding and billing specialists: "a lot of money is spent on that and patients and the American public pay for it.")
More to the point, such a profusion of dubiously necessary data is at cross purposes with the "modern, app-based world," he said. As we move toward a healthcare ecosystem where patients' health records are readily available on smartphones, "we want those notes to reflect the care you receive – not just billing boilerplate."
To the question of whether reducing the documentation requirements would lead to less data and perhaps undermine analytics efforts, Rucker said it would actually be the "exact reverse."
He called templated text the "anti-matter of information," creating a "classic signal to noise problem" for data governance efforts.
By "taking the clutter out," he said, it would be a very powerful boost for EHR efficiency and better algorithms for quality improvement.
Indeed, added ONC Chief Medical Officer Thomas Mason, MD, the proposed rule – if finalized, it will take effect in 2019 – will have a significant impact on EHRs and usability.
The American College of Physicians has called documentation burdens the number one usability challenge, he pointed out. By ameliorating them, it will lead to physician effectiveness and efficiency, innovation, improved data analytics and a clearer focus on patient engagement.
Centegra Health System opted to participate in CMS' Bundled Payments for Care Improvement initiative. But at first, it wasn't sure how it was going to track, chart and monitor a patient's progress throughout a full 90-day episode of care.
None of Centegra's existing systems allowed it to chart pre-hospitalization or post-hospitalization, and it had no common platform for the various post-acute partners to be active participants in the care, with the exception of manual tracking, phone calls, faxing and so forth. All options were antiquated and time-consuming and fraught with missed opportunities.
So the health system turned to PreparedHealth's enTouch technology, a mobile communications platform for providers designed to reduce time and waste involved in transitioning patients from one facility to another and increase visibility for all caregivers involved with a patient's care. It has been using the platform for 18 months and now is rolling it out to all hospital discharges.
There are a variety of vendors of clinical communications technology with platforms on the market today. These vendors include Everbridge, IBM, Mobile Heartbeat, PatientSafe Solutions, Voalte and Zipit Wireless.
"The web-based system and app allow for communication and alerts to various partners in a patient's extended care team. Think of a HIPAA-compliant Facebook," said Astrid Larsen, director of care coordination at Centegra Health System. "We have extended its use to the discharge planners and designated nurses at our skilled nursing facility and home health care partners."
The fact that Centegra case managers are now able to know in real time any changes in the condition of their patients provides a proactive rather than reactive approach to intervention.
"For example, while we do not expect our case managers to work 24/7, they receive real-time alerts," Larsen said. "In one case, a patient was starting to have a decline in a post-acute facility. It was a Sunday night and the platform sent an alert that the patient was going to be seeing their primary care physician first thing in the morning. No one called the case manager but she was able to see an alert come through on her mobile app."
This notification did not interrupt the case manager's weekend but did allow for her to plan her morning the next day. She proactively met the patient at his appointment and helped problem-solve to avoid a readmission.
"Our referral process is cumbersome and time-consuming," said Larsen. "We make a phone call to a post-acute provider. The post-acute provider then has the responsibility to access our EHR to pull the pertinent information to determine whether or not they can accept the patient. The post-acute provider then calls the case manager back to discuss and ask any questions. They also often have to ask for additional information that the case manager then has to locate, print and fax."
In the new process, the case manager places a referral request through the platform, the post-acute care provider has all pertinent information via the platform – the data feed to the platform from the EHR – and responds to the case manager with an acceptance or not. Any additional questions can also be placed through the platform, if needed. No need to make additional calls, navigate an EHR, print and fax information, or leave messages for a callback.
"We track the percent of patients the case management team is involved with," said Larsen. "Our goal is always 100 percent, but this is not feasible with the number of case managers and the responsibilities their roles entail along with providing quality, patient-centered care, which takes time, kindness and genuine caring with the patients."
Centegra puts a strong focus on the patient first and the bulk of staff time should be spent in conversations with patients and families, she added, explaining that eliminating inefficiencies with the tedious tasks case management faces is paramount to this goal.
"Two years ago we averaged a 65 percent patients seen rate," she said. "Last month we hit 91 percent, and that was with a reduced number of FTEs."
For 2016, annually the organization had a 42 percent congestive heart failure readmission rate over a 90-day period; for 2017, it did better and dropped to 35 percent congestive heart failure readmissions over a 90-day period, said Heather Brown, BPCI congestive heart failure case manager. Currently, the organization is on track at about 30 percent congestive heart failure readmissions for 2018, she added.
"For congestive heart failure patients, we are making great strides with preventing readmissions from a home health standpoint, especially with our three top providers and their leadership teams that are so invested in our patient population and our program," she said. "They have worked really well with us keeping us in the loop of what is going on with the congestive heart failure patients for symptom management and education, communication with physicians and other patient caregivers."
The biggest success story of the organization's joint bundle is post-acute care utilization – patients going to certain levels of care and then how long they are there, said David Liss, BPCI total joint case manager. Collaboration through communication is the needle on which the platform has directly had an impact, which is reflected in the length of stay at post-acute care centers.
The percentage of patients going to a skilled nursing facility in 2016 was 54 percent; in 2018 to date, it is 20 percent. The average length of stay at a skilled nursing facility in 2016 was 12.6 days; in 2018 to date, it is 8.0 days. The percentage of patients going to home health in 2016 was 95 percent; in 2018 to date, it is 72 percent.
“The increase in efficiencies allows us to save money by providing better value to our patients," Larsen said.
Contrary to current levels of frustration among clinicians and other users, EHRs hold the power to positively impact patient care. But that takes a more thoughtful and phased approach than simply implementing a new electronic health record platform or upgrading to the latest version.
Instead, hospitals should proceed at a realistic and reasonable pace when rolling out baseline functions, turning on features that have matured since the initial installation, and gradually optimizing the overall functionality and user experience if they hope to achieve gains in quality and performance.
Consider the evolution of EHRs: Between 2008 (when the tech was relatively new) and 2013 the electronic records software went from being linked to an 11 percent higher 30-day mortality rate to being associated with a .09 percent lower rate against the same metric.
Those are the major findings of a study published in Health Affairs. But what fueled the about-face and how did hospitals and technology vendors turn the negative into a positive? Patience and pacing.
Don't expect EHRs to evolve overnight
“Healthcare is complex, EHRs are complex,” said Julia Adler-Milstein, an associate professor of medicine and director of the Clinical Informatics and Improvement Research Center at the University of California San Francisco School of Medicine. “The two together are extremely complex and this idea that we put the two together and the next day healthcare would get better was naive. Most other industries it took a decade for IT to really transform.”
Researchers looked at national Medicare hospital claims for 3,249 non-federal, acute care hospitals from 2008 to 2013, since national data only started in 2008 and not that many hospitals had a lot of EHR functionality before then. They also used data for 2014 from the American Hospital Association Annual Survey Database, including its Information Technology Supplement. They then created a data set that contained annual measures of hospital EHR adoption, characteristics, and mortality performance.
But they couldn’t just ask whether the EHR worked or not. More specific information was needed. So they analyzed how many baseline functions each hospital initially adopted, looked at how its EHR use and optimization progressed over time (also known as maturation), and examined the pace at which new functions were adopted.
“It’s rare for hospitals to go fully paper to fully digital. Most often, new functions are added over time. So the pace at which that happened is the third component. On the one hand, there could be an argument for moving quickly as you can to a fully digital environment because there are some risks to being partly digital and parlty paper. But on the other hand you hear a lot about change fatigue and how much can an organization take on. That’s why that third piece was interesting too,” Adler Milstein said.
Indeed, as the system and its users’ adeptness at navigating the software interfaces progressed over time, study results showed that upturn to a .09 percent lower mortality rate. Logically, adding new baseline functions over time was also linked to lower mortality rates.
Why pacing new EHR functionality is critical
Average adopters, meaning those that had a baseline adoption close to the average rate of 5 functions, fared better than those hospitals that didn’t adopt any, with .67 fewer deaths per 100 admissions.
The takeaway here is that hospitals and the people who work in and run them should expect performance-related gains from EHR adoption to take time. Those gains can be augmented when coupled with robust EHR support and EHR-enabled quality improvement efforts, and this should inform how many functions are adopted at first, how many are added each year, and the expectations that are reasonable to have for gauging results along the way.
“It is possible that starting with many functions or adding many new functions could have the unintended consequence of harming performance, as a result of change fatigue or diversion of attention away from more critical priorities,” the study said.
Adler-Milstein added that it is also crucial to make sure you are constantly improving, not viewing the EHR adoption as one time thing that can be done before moving on to the next IT project.
“It’s really a tool that makes you think about how you do everything in the hospital and you need to continue to improve the EHR itself and how you deliver care. Don’t shy away from continuing to add,” she explained. “Continue to optimize what you have and continue towards full digitization. But remember it’s not the technology that’s going to do it. It’s the organization that has to figure out how to use the technology in a beneficial way.”
In an effort to assess how electronic health records are actually used in by physicians, researchers from American Medical Association and MedStar Health took a look at clinical workflows at four health systems – two that use Cerner and two that use Epic.
Their findings, published this month in the Journal of the American Medical Informatics Association, point to wide variation in how EHRs are put to work and suggest that vendors could do well by implementing performance standards to optimize usability and improve patient safety.
Researchers from MedStar's National Center for Human Factors and the AMA examined how a dozen or so emergency medicine docs at each location completed six specific scenarios – two each for diagnostic imaging, laboratory and medication – in their Cerner and Epic systems. They tracked them by collecting keystroke, mouse click and video data.
"There was wide variability in task completion time, clicks and error rates," according to the report. "For certain tasks, there were an average of a nine-fold difference in time and eight-fold difference in clicks."
Such a wide variation points to the need for system optimization, researchers concluded, noting that smart EHR implementation, in tandem with good design and development on the vendor side, is "critical to usable and safe products."
Some of the differences in performance were striking. For instance, completion of an imaging order in one location took just 25 seconds at one health system, but more than a minute at another.
Placing an order took eight mouse clicks at one hospital, meanwhile, but at another site the same task averaged an astounding 31 clicks.
Researchers found that one location had no errors when ordering medication in the EHR – while another had a 30 percent error rate.
“While there are many benefits to using EHRs, there are also usability and safety challenges that can lead to patient harm," said Raj Ratwani, center director and scientific director of the MedStar Human Factors Center, and the study's lead author, in a statement.
Part of the reason for this wide variation of usability and efficiency is that most EHRs are customized and configured by vendors and providers as they're implemented. Even though EHR vendors are required by ONC to incorporate principles of user-centered design and conduct usability testing, once systems are rolled out in real-world settings they're often very different from the ones that were tested and certified by the government.
The report suggests that basic performance standards EHR design and implementation could go a long way toward addressing this variation – and vendors and providers should work together to embrace them to ensure optimal usability and safety.
"Our findings reaffirm the importance of considering patient care and physician input in the development and implementation of EHRs," said Michael Hodgkins, MD, chief medical information officer of the AMA, one of the study's co-authors.
"There are multiple variables impacting the end user experience that contribute to physician burnout, a diminished patient-physician relationship, and unrealized cost savings. While design can be an important factor, so too can implementation choices made onsite."
Missouri-based Cass Regional Medical Center brought its EHR system back online on Monday, one week after it was hit by a ransomware attack.
Hackers got into the system around 11 a.m. on July 9. Officials promptly shut down its EHR to prevent further damage or access. The health system maintained patient care during the attack but chose to divert trauma and stroke victims to ensure they received the best care.
Cass Regional initiated its prepared incident response just 30 minutes after discovering the attack, which allowed officials to maintain care.
Officials quickly launched an investigation with the help of a third-party vendor, which determined the hackers performed a brute force attack on its remote desktop protocol (RDP) to infect the system with the ransomware. The notice did not mention how much the hackers demanded in ransom.
While officials did not confirm the type of ransomware used, brute force attacks on RDP are used by the notorious SamSam ransomware variant. SamSam was responsible for shutting down Allscripts for about a week in January.
RDP is widely used to give remote access for legitimate business purposes. However, a hacker can use the port to jam ransomware into a network. The trial-and-error method attempts to decode encrypted passwords or other encryption keys using brute force.
While RDP is a legitimate port, a lack of robust security, including unsophisticated logins and passwords, make RDP a vulnerability. In fact, a brute force attack is hard to execute when an organization has multi-factor authentication implemented on its system.
Since the attack, officials said they’ve modified their systems to eliminate the risk.
Other healthcare organizations can shore up RDP vulnerabilities by implementing stronger security controls. That includes adding antivirus on all endpoints, including servers and RDPs, according to CynergisTek Executive Vice President of Strategic Innovation David Finn.
“It needs to be on all of your endpoints,” Finn said. “We sometimes forget about those servers being endpoints.”
Further, organizations can make sure to close ports that don’t need to be opened, and make sure that all public-facing access points are only open to those who need access.
Prescription opioid abuse in the U.S. is soaring. As the country's policymakers grapple with how to address this national emergency, great progress has been made in the state of Maine, which this month marks the first anniversary of a state law requiring the use of electronic prescribing of controlled substances technology.
Since Maine's mandate went into effect in July 2017, making it only the second state in the country with such a law after New York, a significant number of physicians have responded to the new law, known as Chapter 488, which prohibits hand-written paper prescriptions for controlled substances.
Maine now ranks No. 3 among the states for leveraging EPCS to fight against the opioid epidemic, and more than half of Maine prescribers now are EPCS-enabled (51 percent) compared to the national average of 22 percent, according to the Surescripts National Progress Report.
"The opioid issue has created challenges for those prescribing but it has also given them a more effective tool to treat their patients who are dealing with long-term chronic pain issues," said Maine Republican State Senator Andre Cushing III, co-chair of the state's opioid task force. "In many cases, it has opened discussions about how to effectively treat their underlying problems and perhaps move away from continued use of opioids."
It creates a better safety net for those who have developed a significant addiction and have been seeking multiple means of access to opioids, Cushing added.
"Maine's governor was committed to a multiple-pronged approach to fighting this battle against misuse and the associated dependence on prescription drugs," Cushing explained. "His administration, with the help of the medical association and our department of HHS, crafted the plan and then worked through the implementation process to educate providers and amend the law to address some of the challenging issues that arose."
Prior to the law's enactment, electronic prescribing of opioids in the state was very limited, down in the 1 to 2 percent range, said Gordon Smith, executive vice president of the Maine Medical Association.
"Enactment of the mandate dramatically increased EPCS in the state," Smith said. "The two lessons learned: A) While difficult for prescribers, a legal requirement will dramatically increase EPCS in a state, and, B) There will be some pushback, largely from small or solo prescribers who do not have access to EHR systems that can incorporate the change and thus have to go to some expense to buy software or hardware to meet the requirements of the law."
Prescribers did have the ability to apply for a waiver from the state and the state was quite generous in granting them, which greatly helped in the implementation, he added, explaining why almost half of providers are still not in compliance.
"While nearly all pharmacies were already able to accept electronic prescriptions for controlled substances, not many prescribers had implemented the technology to send them."
Ken Whittemore Jr., Surescripts
"The biggest obstacle going forward is the enormous pressure on primary care from all directions and the lack of adequate reimbursement to meet the demands of laws such as Chapter 488," Smith said. "The unfunded mandates can be handled by the larger systems but the small and solo practices – for example, a psychiatrist practicing part-time – struggle."
In a perfect world, mandates such as Chapter 488 should be funded and paid for through an appropriation when enacted, he said. Without funding and adequate training, this type of legislation contributes to primary care burnout, he added.
E-prescribing vendor Surescripts has helped many physicians in Maine conducting EPCS. The vendor is an example of other organizations joining state organizations to help push the adoption of EPCS.
"Maine was one of the first states in the nation to enact a law that requires the use of e-prescribing for all opioid prescriptions," said Ken Whittemore Jr., vice president of professional and regulatory affairs at Surescripts. "While nearly all pharmacies were already able to accept electronic prescriptions for controlled substances, not many prescribers had implemented the technology to send them."
Surescripts, he said, worked with a number of organizations across the state to get the word out that the mandate was coming and that the technology was available. One example of how it educated prescribers is an online resource it developed at GetEPCS.com. It includes videos, Q&A and other resources designed to make it easier for prescribers to get up and running quickly.
In an industry such as healthcare, where imperatives shift by the month and technology evolves by the day, the issues competing for space in the minds of IT decision-makers are constantly changing too.
Several key priorities are well known, others are perhaps surprising – but all are indicative of where other CIOs should be paying attention if they aren't already.
Interestingly, finding ways to improve digital health and optimize the patient experience was far and away the top to-do for those tech decision-makers who gathered at a recent roundtable: 17 out of 22 said those twin goals were leading their agendas, according to consultancy Impact Advisors.
Other high priorities: seeking better strategies for IT cost containment and value realization, and sparking new efforts to drive innovation. (Cybersecurity, it will not surprise you, was another big concern across the board.)
Patient engagement and experience predominates
Whether on the patient side (inpatient patient experience technology, wearable biosensors, care-management apps for population health) or the provider side (care coordination tools, next-gen decision support), emerging digital health tools are of keen interest for CIOs looking to make investments, the new report shows.
More than 80 percent of them cited patient engagement and experience a chief goal, according to Impact Advisors – the most frequently mentioned priority by a big margin.
Impact Advisors convened nearly two-dozen IT execs from leading U.S. health systems including Advocate Aurora Health, Henry Ford Health System, Methodist Le Bonheur Healthcare, UCLA Health, University of Chicago Medicine to come to its findings.
That high level of interest "underscores a growing recognition – especially among industry leaders – about the critical need to be able to compete on convenience, access to care and value (as defined by patients)," researchers from the consultancy said.
"The focus by participating CIOs on digital health, virtual care and the overall patient experience is also notable because health-delivery organizations are no longer just competing with other hospitals, health systems and physician practices," they noted. "New, non-traditional players have also emerged, such as retail clinics from major pharmacy chains and onsite workplace clinics increasingly being offered by large employers."
Making the most of IT investments
Even as new and ever more envelope-pushing technologies crowd into a healthcare space that's fast-reshaping itself, CIOs are also looking to gain efficiency and top performance from the IT infrastructure they already have in place. More than 60 percent of those at the roundtable cited containing costs or improving IT value as a top priority.
"As recently as even five years ago, many hospitals and health systems nationwide were investing significant amounts of money to implement a new enterprise EHR– or upgrade an existing one – to maximize meaningful use incentive payments," according to Impact Advisors.
"In some cases, implementations were rushed or narrowly focused on the capabilities needed for meaningful use," they add. "Fast forward to 2018, and financial challenges are forcing CIOs to stretch the technology dollar more than ever. At the same time though, there is also now significant pressure internally to demonstrate tangible value from existing IT investments—particularly the enterprise EHR."
Another "I" word comes to the fore
But in the post EHR era, innovation is the ultimate goal– nearly two-thirds of CIOs said that imperative, which admittedly means different things to different technology decision-makers, was a key priority for their hospitals and health systems.
Impact Advisors noted that they're furthering these goals in a variety of ways: launching dedicated innovation centers, hiring chief innovation officers and expanding the types of organizations – both inside and outside of healthcare – with which they forming strategic partnerships.
"Although approaches to innovation range widely, one consistent theme in the discussion was the importance of putting more structure and governance behind innovation to ensure efforts are better aligned with the organization’s overall strategic goals," according to the report, which noted that there was little mention at the roundtable of buzzed-about tech such as FHIR or blockchain.
Healthcare providers are under growing pressure to do more with the data they manage. Especially given the advent of advanced analytics, AI and machine learning, healthcare must shift to the cloud to improve the secure delivery of patient care.
Precision medicine is something of a Holy Grail in healthcare: Being able to deliver personalized treatments to individual patients to best cure specific ailments is the ultimate in healthcare.
While precision medicine is still fairly nascent today, one can look forward and see what’s coming down the line to change the way personalized health can be delivered. And though precision medicine is a tricky arena to predict, experts have their ideas on where the complex healthcare field is heading, and what the next generation of precision medicine will look like.
The term “next-generation technology” has different connotations for different healthcare organizations, depending on where they are on the innovation continuum; but machine learning-enabled medical image analysis software should be at the top of the list, said Paul Cerrato, an independent healthcare writer who has collaborated on three books with Beth Israel Deaconess System CIO John Halamka.
“To date, machine learning algorithms are now capable of delivering more accurate interpretations of radiological images than human ophthalmologists, and interpretation of dermatological lesions that is just as accurate as that provided by dermatologists,” Cerrato said. “For instance, with the use of deep neural networks, it is now possible for computers loaded with the appropriate software to diagnose skin cancer as well as experienced dermatologists.”
Similarly, Google researchers have demonstrated that a deep learning algorithm is more effective at diagnosing diabetic retinopathy than experienced eye doctors and residents. That feat was accomplished by using the software to scan more than 11,000 retinal images.
Additionally, hospitals need to find a way to integrate genomic data into their EHR systems so doctors can gain quick access to this data at the point of care and advise patients on how it should impact their treatment, Cerrato said.
“But raw genomic data can’t just be dumped into the EHR,” he said. “Provider organizations need an add-on that turns the data into actionable insights that doctors can use.”
"Most doctors are ill-prepared for [patients with genomics data] now, but they must prepare for this to remain viable and competitive in a market where con"
Joel Diamond, MD, 2bPrecise
Beyond cancer: Pharmacogenomics
While most of the actionable data today is in the field of cancer care, there is another area that is probably more important for primary care physicians and will eventually have a larger impact in clinical outcomes: Pharmacogenomic testing.
“The list of drugs that are affected by an individual’s genetic variants is very long,” Cerrato explained. “Certain mutations can increase the effects of specific drugs, making them more toxic. Other mutations can cause a faster breakdown of drugs, decreasing their effectiveness. The FDA has approved pharmacogenomic testing for several of these drugs. The problem to date is that third-party payers have refused to reimburse for most tests.”
But the scientific evidence to support the value of these tests is growing rapidly – to be ready for this future, providers should have the genomic testing in place, he added.
Joel Diamond, MD, chief medical officer of Allscripts subsidiary 2bPrecise, said there will be a continued “greater-than-exponential” rise in the new types of -omics information.
“We haven’t yet conquered the genomics data challenge and soon we will see the influx of other data types – proteomics, metabolomics, transcriptomics, the microbiome, personal device data, etc. – and we will have the similar challenges of making sense of the information within a specific patient encounter,” Diamond said. “There are no standards in vocabularies and terminologies. It is not binary data, and will all rely on interpretations. There will be an increasing need for the merging of this data with clinical information, and the marrying with the equally as rapidly evolving evidence-based science.”
Elsewhere, healthcare will see the rapid rise of consumerism, forcing more transparency and competition in the provider market, Diamond added.
“This will be the case with genomics and precision medicine, with most people having rich data on their genome and expecting their providers to know what to do with it,” he said. “Most doctors are ill-prepared for that now, but they must prepare for this to remain viable and competitive in a market where consumer demand will be like nothing we have seen previously in healthcare.”
And gene therapy is another promising next-generation functionality that will change the way care is delivered, he added.
“CRISPR is first to bat and with it comes a myriad of ethical, financial and IT challenges,” he said. “Health systems are still worrying about interoperability and things that technology has been available to address years ago. They will need a solid foundation in place if they are going to be ready to apply this clinically, outside research labs.”
"As [SMART applications and FHIR interfaces] evolve, the ability to ‘write once, run anywhere’ could be as significant to medicine as HTML has been to general applications."
Don Rule, Translational Software
Operationalizing precision medicine
A key function of operationalizing precision medicine is the ability to access genetic test results from the clinical context, within the existing workflow, whether the results are stored in the EHR or an ancillary system like a PACS or medication management system.
This will require interoperable IT tools and application programming interfaces that are able to integrate genomic data for use with existing systems without significant IT development or impact to existing system performance, said Don Rule, CEO of Translational Software, a genomics clinical decision support and precision medicine company.
“APIs developed using the Fast Healthcare Interoperability Resources specification, an open-sourced standard based on HL-7 for exchanging health information to ensure interoperability and security, can facilitate integration of genomics data and test results seamlessly and cost-effectively to deliver on this ability at the point of care,” Rule said.
The ability to plug in new forms of clinical decision support and other healthcare apps that make data useful within the clinical context is another next-generation precision medicine necessity, Rule said.
“The FHIR standard helps to normalize the format of data sent ‘over the wire’ between systems, and layered on top of this is the need for a Substitutable Medical Applications, Reusable Technologies (SMART) health data layer that builds on FHIR to facilitate the creation of apps for healthcare,” he said. “Using an EHR that supports the SMART standard, clinicians can access SMART apps like genomic decision support within their existing workflow to enable precision medicine.”
SMART provides a common vehicle for authentication and authorization with the host system that allows a conformant application to function with any compliant EHR without specialized knowledge of the system.
“SMART applications are in their infancy now because many FHIR interfaces are still read-only, and most do not support the CDS-Hooks standard for launching applications based upon events that occur within the EHR,” Rule explained. “However, as these evolve, the ability to ‘write once, run anywhere’ could be as significant to medicine as HTML has been to general applications.”
What tech is shaping the future of healthcare IT?
In his first major speech since becoming the new Health and Social Care Secretary, Matt Hancock has put information technology atop his list of priorities for improving the National Health Service.
And he's backing his words with big money – the UK will invest around $540 million for hospital IT, according to reports, with another $98 million earmarked to help those trusts who still rely on paper make the move to electronic health records.
Hancock said his top three priorities for the NHS were "workforce, technology and prevention," and he said the millions in new funding were needed to boost the efficiency and morale of providers and the engagement of patients.
"You know better than me the pace at which modern medicine moves and so it’s crucial that your training looks to incorporate new technology that can save you time and offer better care," he said, in a speech delivered to staffers at West Suffolk hospital. "I want to make sure you have the access to the skills you need to make the most of these new opportunities."
Hancock noted how the status quo – where "decisions on health and care have seemed to involve a trade-off: improving patient outcomes at the expense of placing ever more pressure on staff, while reducing the demands on staff has been seen to have an impact on patient care" – was unacceptable.
"Technology and data innovation offers an opportunity to move past this binary approach," he said.
Specifically, Hancock noted the need to increase patient safety with barcode scanning, boost engagement through mobile technology and improve clinical workflows with voice recognition software.
Recognizing that tech transformation "requires upfront investment," he said the new half-billion pound package would "help jump-start the rollout of innovative technology aimed at improving care for patients and supporting staff to embrace technology-driven health and care.
"More than [$524 million] will go towards new technology in hospitals which make patients safer, make every pound go further and help more people access health services at home," said Hancock. "A further [$98 million] is available to Trusts to help them put in place state-of-the-art electronic systems which save money, give clinicians more time to spend on patients and reduce potentially deadly medication errors by up to 50 percent when compared to the old paper systems."
And that money was "just the start," he said. "The entire $26 billion proposed for the NHS will be contingent on modern technological transformation."
Along with the technology investments Hancock said he would prioritize new data standards – "getting the data architecture right," while "allowing for innovation at all levels while protecting the highest standards of privacy" would be key, he said – and work to foster culture change.
"I want to work with everyone across the NHS and social care system to embrace the next generation of technology," he said.
Robert Wilkie, a Department of Defense under secretary was confirmed as Department of Veterans of Affairs Secretary on Monday, giving the troubled agency a permanent leader for the first time since March.
The vote of 86-9 makes Wilkie the first VA Secretary to not be unanimously confirmed. Nine Democrats and Bernie Sanders, I-Vermont, dissented. Sanders expressed concern that Wilkie would align with the Trump administration to privatize VA healthcare.
The agency has been operating without a permanent VA Secretary since March, when
President Donald Trump fired David Shulkin, MD. At the time, Shulkin was amidst contract negotiations with Cerner to replace the VA’s legacy EHR. Wilkie stepped in as acting secretary and signed the contract in May.
After being nominated, Wilkie went back to the DoD to await his confirmation hearing. Peter O’Rourke has been overseeing the agency in the interim. Trump’s original nominee for the role, White House physician Ronny Jackson, MD, withdrew amid claims of workplace misconduct.
Wilkie easily sailed through his Senate Veterans Affairs committee hearing, with only Sanders dissenting. And the hope, according to some of the senators at yesterday’s hearing, is that Wilkie will alleviate some of the turmoil at the agency.
“We know the things that we've gone through with some of the previous appointees, and some of the problems at the VA now have a chance to be overridden and solved, and we'll step forward with a new day for the VA,” Sen. Johnny Isakson, R-Georgia, said.
“We no longer want someone who's going to make excuses for the VA,” he continued. “We want someone who is going to make a difference.”
To Senate veterans committee ranking member Sen. Jon Tester, D-Montana, that difference will be the responsibility “to right that ship.”
During his confirmation hearing, Wilkie said that prioritizing the EHR modernization project would be his top priority as secretary.
“[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 during the hearing.
It’s been a year since Shulkin announced that the VA would overhaul its EHR and go with Cerner. In June, O’Rourke told Congress that the first install would be fully functional by 2020 and begin in the Pacific Northwest.
Just last week, O’Rourke named the Office of the National Coordinator Deputy Genevieve Morris to lead the new Office of Electronic Health Record Modernization.
The Icahn School of Medicine at Mount Sinai and the Institute for Next Generation Healthcare announced the opening of the Center for Biomedical Blockchain Research to use new technologies and data to work on healthcare and medical science problems.
The new centers come as many health systems are curious about real-world use cases and deployments of blockchain and analyst firms IDC and Gartner tell IT executives that the time to create strategies around the technology or risk being left behind by rival hospitals that move first.
Joel Dudley, executive vice president of Precision Health at Mount Sinai, heads the new center. Dudley’s research focuses on machine intelligence to solve problems in biology and the new center will complement that work by developing predictive health applications from EHRs, wearables, and related digital health information.
He was the co-founder of a venture-backed health tech startup and served as a senior data scientist at Pivotal Software, where he delivered predictive models for multibillion-dollar companies in healthcare and biotech.
Mount Sinai said the new center’s research will lay the groundwork for its forthcoming industry partnership program aimed at companies looking to develop biomedical blockchain that helps identify and address problems in clinical medicine and biomedical research.
“This experience will allow us to address many of the most promising uses for blockchain in biomedicine with the goal of improving healthcare delivery and reducing costs,” Dudley said in a statement. “Many companies are already exploring the use of blockchain technologies in biology and healthcare.”
Potential applications include drug development, clinical research trials, improving quality control in the pharmaceutical industry to reduce counterfeit drugs, and enhance research reproducibility.
“Our aim is to understand how blockchain and associated technologies can be applied to unmet needs in healthcare and biomedicine,” Dudley added.
Dudley and his colleagues expect early use cases to emerge from areas where existing systems and approaches fall short.
Emergency room physicians are almost always asking themselves, “What’s in front of me right now? Is this independent from the problem the patient has or is it part of the problem?” To answer these questions effectively, the physicians must know a lot about many different diseases.
“To master skin diagnoses, for example, I read a lot of atlases and earlier books from dermatologists, but the problem myself and my colleagues would run into is that we had the information available but not the visual component to answer the question, ‘What is it I’m looking at?’” said Brian Browne, MD, chair of the department of emergency medicine at the University of Maryland.
To overcome these challenges, Browne and his team deployed an imaging-based, artificial intelligence-powered clinical decision support tool from vendor VisualDx. The tool uses more than 100,000 medial images, available through a desktop or a smartphone.
Clinical decision support is a thriving area in the field of health IT. Vendors include Automated Clinical Guidelines, Epic, Information Builders, National Decision Support Company, Outcome Health, Pepid, TransformativeMed and Wolters Kluwer.
“It gives us more than any medical images we could find on the Internet and gets us over the challenge of having so many images to look at but not the informational context of what it actually is that we’re looking at in the ER,” Browne said.
"The best part is that we’re still bringing our expertise as trained physicians to the table when diagnosing so it truly is a tool that helps us to do our jobs more effectively and safely."
Brian Browne, MD, University of Maryland
VisualDx works by using artificial intelligence to compare hundreds of thousands of medical images against the symptoms entered by physicians into the platform. The tool then provides a physician with a few different possibilities for what the disease may be, and it enables users to add in additional symptoms and patient demographics to deliver a more accurate diagnosis, Browne said.
Additionally, the University of Maryland has VisualDx integrated into its Epic EHR such that clinicians can use it via the electronic health record, or on desktop or mobile devices.
“The best part is that we’re still bringing our expertise as trained physicians to the table when diagnosing so it truly is a tool that helps us to do our jobs more effectively and safely,” Browne added.
Browne recently had a case where a woman in her mid-fifties had come into the emergency room with an unusual growth on one of her fingers. She had been trying for weeks to care for the issue at home, which included cutting the growth off and any other means she felt necessary. All of which were to no avail as the growth continued to return and get bigger.
“She finally came into the ER and shared her story with us,” he said. “I had a few suspicions in mind for what the growth may be, but the diagnosis wasn’t immediately clear.”
Browne pulled out his smartphone to I had used the software on my smartphone to confirm narrow the diagnosis down to a few variables.
“After filling in the demographics, sharing a photo and receiving possible diagnoses back, I was relieved to have the second opinion on what it actually was I was looking at,” Browne said.
He had believed he was seeing the first diagnosis recommended, which was much more life-threatening, but it was actually the second diagnosis option presented, a pyogenic granuloma.
“The biggest takeaway from this scenario other than coming to the correct conclusion was that I was also able to build a more trusting relationship with the patient,” he said. “I had been using the tool in front of her and guiding her through the final diagnosis I had come to on the platform. This made her feel much more secure that this is exactly what she had, and it eliminated the feelings she was having of being alone in the diagnosis process.”
Browne was also able to treat her issue within the emergency department and avoid sending her to another physician or running countless, potentially unnecessary tests.
This example highlights what the imaging-based clinical decision support technology brings to the table when it comes to improving care and trimming costs.
We’ve officially entered into the “dog-days” of summer here in the mid-Atlantic states. When I think back to the biting cold wintertime in January it seemed that summer would never appear, yet it has arrived in full force. I use this metaphor because it closely resembles the electronic health record (EHR) optimization challenges that many of us face.
After years of toiling, building and deploying, users are asking for more out of their EHR; and rightfully so! Industry statistics indicate that users in all industries tend to use between 50 percent and 60 percent of the functionality provided in their core application suite.
Given this stat, providing on-going education and system personalization to the staff becomes a natural next step and an excellent opportunity to empower users with more system proficiency. When clinicians are live on the EHR for several months after implementation they gain a better idea of how the system flows and are more familiar with specifically what needs to be adjusted.
In addition to building upon user education, we have also taken the step to administer the KLAS organization’s Arch Collaborative Survey, which measures a user’s overall satisfaction with the EHR. This is not a survey that is for the faint of heart as the results — and most particularly the comments — can really get your attention.
The feedback serves as one way to measure your community’s overall satisfaction and compare the results to other organizations that have also taken the survey. From my perspective, results from surveys such as the Arch Collaborative along with on-the-ground feedback are excellent data points in planning your optimization strategy.
Interestingly, through our efforts, I have yet to find an “ah-ha” moment from any of the feedback received. In general, clinicians are busy and more of the electronic work effort falls upon their shoulders. Clinicians want ease of use getting data into the EHR and, in turn, would like more value delivered in getting data out of it.
This latter point seems to be the one in which most vendors and organizations continue to struggle. Addressing these struggles can be tedious work as time constraints, varying levels of system knowledge and overall interest varies from clinician to clinician.
Thus, a consistent approach of ongoing training (often shoulder to shoulder), personalization of system flows and improved access to knowledge are tried and proven roads to ongoing empowerment as we seek to build new inroads in the data value and knowledge transformation territory.
Though the dog days of summer will soon come to an end as the brisk autumn days’ approach, optimizing is a year-round effort that will span many more seasons to come and go.
Mike Restuccia is the CIO of Penn Medicine.
Get ready for this: Interoperability is on the cusp of a breakthrough akin to AT&T customers being able to pick up their phones and call Verizon subscribers. That's a convenience that's long been taken for granted, of course. So why has it taken so long for clinicians to easily access patient data in competing EHRs.
We're almost there, people – ready for a significant step in the healthcare system's digital transformation journey.
Carequality and CommonWell are poised to go fully live with a health information exchange encompassing all major EHR vendors, as well as subscribing hospitals. And when they do, some 80 percent of doctors will be able to share patient data among competing EHRs, said Micky Tripathi, who is on the board of both CommonWell and The Sequoia Project, which oversees Carequality.
That critical mass is invigorating. But even more important is how this new phase will change current thinking about the future of FHIR and open APIs, and lay the foundation for really using data in a meaningful way. That's the exciting part.
"This will be a signature moment in nationwide interoperability," said Tripathi, who is also CEO of the Massachusetts eHealth Collaborative and a veteran of interoperability working groups at the Office of the National Coordinator for Health IT.
"I'm very sanguine about where interoperability is and where it's headed," he said. "You can decide whether that means I'm biased or bullish, but I think it's more the latter."
Tripathi is not the only one.
First, a quick bit of background
In December 2016, Carequality and CommonWell revealed plans to work together advancing connectivity and health information exchange. That collaboration would see CommonWell implement Carequality, so its members can query each other, while Carequality would develop a version of CommonWell's record locator service that its members could use to look up patients across the network.
"Connecting those is actually happening," said Tripathi. "There's been a lot of testing and the hope is that it should go full-live by the end of the summer. The biggest breakthrough that will happen when these get connected is providers on one side of that wall will be able to connect with providers on the other side of that wall."
"We've achieved an architectural feat here. And it's up the market to fill in those gaps while we work on APIs and FHIR."
Micky Tripathi, board member on CommonWell and The Sequoia Project
Specifically, a member hospital in either Carequality or CommonWell using, for instance, a Cerne EHR will be able to run queries against another participating health system that houses patient data in Epic's system.
But it's not just about Epic and Cerner. Any hospital using a member EHR vendor will be able to swap data with any other member vendor.
"This is a huge deal as it allows sharing of data between Epic, Cerner and athenahealth users which is most of the EHR market," said Niam Yaraghi, a fellow at Brookings Institution and Assistant Professor of Operations and Information Management at the University of Connecticut's School of Business. "And there are many other partners which make this collaboration even better."
Meditech joined the party in June, for example, when it deployed CommonWell interoperability services (something it had first announced this past summer) and Ohio's Alliance Community Hospital became the first to tap Argonaut Project's FHIR specification for exchanging documents.
CCDs are not interoperability's destination
But wait, wait, hold on – it's time to put all this in perspective. Lest anyone start thinking that interoperability will be solved before Labor Day, it won't. Rather, what will develop is a basic use case: the exchange of Continuity of Care Documents.
Now, that won't mean a California clinician can essentially Google a South Dakota specialist's record about an individual patient to find out a piece of information as granular as medication allergies. Doctors, instead, will get the entire record in a data dump, and a less-than-perfect one at that.
But CommonWell, Carequality and participating EHR makers, taken together, compose enough of the providers in the country that, as we have seen with digital transformation in other industries, once these sorts of efforts hit critical mass the movement becomes something of a foregone conclusion and the laggards will inevitably come along, too, albeit at their own pace.
Carequality and CommonWell's collaboration is not a simple matter of flipping a switch. Rather, unforeseen technical glitches are bound to arise as this infrastructure expands, and it will take time to perfect the health information exchange arrangement.
Yaraghi said technical problems are bound to present themselves; Tripathi said it could take two years or more to completely iron them out.
"We've achieved an architectural feat here," Tripathi said. "And it's up the market to fill in those gaps while we work on APIs and FHIR."
FHIR+APIs = apps way cooler than XML
Health system CIOs, innovators and tech vendors take note: That architecture is right where things get downright interesting.
"This will both free up a lot of resources and also create opportunities to really use the data in a meaningful way," Yaraghi said. "It is exciting."
And it comes at a time when many people in the industry are saying that healthcare needs to reimagine innovation.
"An API-first strategy is a key component of modern system architectures," said John Supra, vice president of solutions and services at the Care Coordination Institute. "That has the potential to both enable and accelerate innovation."
Supra's colleague Shrujan Amin agreed.
"Healthcare needs to focus on fast and easy-to-implement approaches for data sharing and access, through the use of open standards, platforms, and APIs," said Amin, a data scientist at the Care Coordination Institute. "Unlike other industries, healthcare has been plagued with siloed systems, often designed for a single purpose where interoperability success was measured by importing or exporting a file nightly."
Indeed, when the focus transitions from a 1980's healthcare-specific paradigm to a RESTful API, the health industry becomes a promised land for the next generation of bright young developer minds.
"You're not going to get a new grad coming out of MIT who says, 'Yeah, let's do something with XML.' They'll just go get a job with Facebook," Tripathi said. "But FHIR enables the creation of apps and if I have more people coming in to create cool software that will be targeted at diabetics or asthmatics or diabetics with asthma — you can really see how an ecosystem will start to flourish."
Whether the exchange between Carequality and CommonWell goes live this summer or for some reason gets pushed back a bit is beside the point: After lots of work, we are closing in on a signature moment for interoperability that will be here sooner rather than later.
The U.S. Department of Defense will increase its budget for its Cerner electronic health record modernization contract with Leidos by about $1.2 billion, according to a justification and approval document posted late Tuesday.
According to the document, the additional funds will support the added services and capabilities necessary to maintain a standard EHR between the Department of Veterans Affairs and the U.S. Coast Guard.
DoD signed its $4.3 billion contract with Leidos in 2015 for a Cerner EHR system. MHS Genesis is currently in a planned assessment stage but has faced some serious challenges that have been criticized heavily by Congress.
The agency also still is working through the issues brought to light by an Initial Operational Test and Evaluation in March that found the platform was “operationally unsuitable.”
But on Tuesday, Stacy Cummings, program executive officer for Defense Healthcare Management Systems, told the Defense Health Information Technology Symposium in Orlando that the DoD has found “measurable success” in its workflow adoptions and other improvement efforts.
The final test report will come later in the year, with some results expected by the fall, said Cummings. DoD will continue to work with the test communities to gain real-time feedback and to “make sure we’re being as responsive as possible.”
Cummings also announced the next wave MHS Genesis sites, which include: Naval Air Station Lemoore, Travis Air Force Base and Army Medical Health Clinic Presidio of Monterey in California, as well as Mountain Home Air Force Base in Idaho.
As the three agencies continue to push through the setbacks to create a single, integrated EHR, the DoD “needs to acquire the same core capabilities as the VA is acquiring to ensure consistency among the agencies,” according to the budget document.
By raising the budget cap on the project, the DoD will also be able to support the incorporation of the Coast Guard into the existing MHS Genesis project. But it will also support the “extended capabilities that were not available at the time of the original contract and/or were not proposed against the government’s identified requirements.”
The standard platform, according to the document, will include common clinical applications, interfaces and a shared infrastructure that “when configured, results in a much greater commonality in practical workflows, roles, order sets, plans and reports, as well as the training materials to support them.”
Some of these items were not covered by the original contract. Officials said the funds also will cover the technical services and capabilities required to support the shared environments.
On Tuesday, Vice Admiral Raquel Bono told the Orlando audience that DoD continues to progress with the project.
“We need to continue with our forward momentum,” said Bono. “While acknowledging some areas we have needed to make adjustments, we’re progressing forward… We have a lot to share with the broader healthcare community and we are helping to raise the bar in the security environment.”
Prescription drug monitoring programs offer a valuable safeguard against overprescription of opioids, but they aren't perfect. A new technology being piloted at hospitals in Texas aims to complement the use of PDMPs by enhancing physicians' visibility into their patients' opioid exposure, in both hospital and ambulatory settings.
Forty-nine states have embraced PDMPs to varying degrees but, as Healthcare IT News showed earlier this year, those variations in state policy, clinician uptake and efficacy of technology infrastructure mean their true impact on stemming the opioid crisis is yet to be determined.
"In an ideal world we would want the information from a PDMP right in a prescriber workflow," said Cynthia Reilly, director of Pew Charitable Trusts Substance Use Prevention and Treatment Initiative.
Earlier this year, the Texas Hospital Association announced the launch of an analytics technology called Smart Ribbon. Co-developed by THA’s Center for Technology Innovation and vendor IllumiCare, the tool uses HL7 feeds to show physicians clinical and financial data, atop their normal EHR workflows – with the aim of giving them more information about the cost and clinical necessity of the tests they order.
This week, IllumiCare unveiled a new Controlled Substance app for the Smart Ribbon. It uses similar techniques to combine prescription tracking data for opioids and other controlled substance into one place for quick reference, tracking both inpatient and outpatient EPCS data.
More than half of non-surgical patients – and the majority of surgical patients – first get opioid prescriptions in a hospital, the company points out, with the morphine equivalent doses they receive as inpatients often having a predictive effect on their chronic use of opioids once out of the hospital.
Most clinicians don't get to see that data through many existing tracking systems, however, since they only show outpatient exposures reported to state PDMPs.
IllumiCare aims to address that "blind spot," officials said, by showing data from across the continuum of care to help physicians make the best treatment decisions.
The new app, first available to THA member hospitals – offers insight into patients' opioid history prescription history based on PDMP data, but also tracks use in the hospital and shows alerts at peak thresholds of administration.
"While important, accessing only the PDMP gives an incomplete picture of exposure," said GT LaBorde, CEO of IllumiCare, in a statement. "Tackling the opioid crisis requires hospitals to be more proactive in limiting the inpatient exposure that contributes to a person’s chronic use."
Texas Hospital Association CEO Ted Shaw said the work aligns with its priorities in public policy and education on opioid risk management.
Opioid Crisis: Tech fights epidemic
Learn how tech is being used to battle abuse.