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- 09/06/18--14:11: _Athenahealth may fi...
- 09/10/18--07:28: _A look inside Epic,...
- 09/10/18--07:49: _Cerner President Za...
- 09/10/18--09:31: _Machine learning he...
- 10/09/18--10:00: _Policy Enablers and...
- 09/12/18--10:17: _Alameda Health Syst...
- 09/13/18--10:43: _HITECH, Compliance,...
- 09/14/18--06:10: _Former Allscripts C...
- 09/14/18--10:47: _EHR interoperabilit...
- 09/18/18--07:38: _Elliott Management ...
- 09/18/18--09:31: _Senate passes sweep...
- 09/18/18--09:36: _VA will open biddin...
- 09/19/18--05:00: _Interoperability ne...
- 09/20/18--09:24: _Consumerism focus a...
- 09/21/18--12:39: _Duke Health earns H...
- 09/24/18--11:44: _At UCHealth, Rx dec...
- 10/11/18--09:00: _The Future of Medic...
- 09/26/18--05:54: _What innovation loo...
- 09/26/18--06:07: _Maintaining data in...
- 09/27/18--08:05: _Checklist: Moving i...
- 09/06/18--14:11: Athenahealth may find Elliott Management its most promising suitor
- 09/10/18--07:28: A look inside Epic, Cerner and Allscripts app store programs
- 09/10/18--07:49: Cerner President Zane Burke to step down this fall
- 09/13/18--10:43: HITECH, Compliance, and the Growth of the Ransomware Economy
- Call for the U.S. Department of Health and Human Services to "develop best practices for prominently displaying substance use treatment information in electronic health records, when requested by the patient."
- Enable the Centers for Medicare and Medicaid Services to test various models that "provide incentive payments to behavioral health providers for the adoption and use of certified electronic health record technology to improve the quality and coordination of care through the electronic documentation and exchange of health information."
- Require physicians to prescribe Part D-covered controlled substances electronically and direct CMS specify a list of exceptions and outline the penalty for failure to comply when the e-prescribing requirements.
- Require that prior authorizations related to Part D e-prescriptions use a standard format to improve the way the authorizations are processed.
- Provide support for states and localities to improve their Prescription Drug Monitoring Programs and "implement other evidence-based prevention strategies, encourages data sharing between states, and supports other prevention and research activities related to controlled substances."
- Reauthorize HHS's NASPER grant program, allowing states to "develop, maintain, or improve PDMPs and improve the interoperability of PDMPs with other states and with other health information technology."
- Authorize new program through the Substance Abuse and Mental Health Services Administration for the establishment of comprehensive opioid recovery centers. "These entities may utilize the ECHO model, which supports care coordination and services delivery through technology."
- Give support for states to collaborate on strategies to improve care substance-exposed infants, including the development and upgrades of new technology and monitoring systems to more effectively implement plans of safe care.
- Require CMS to set up an online portal to enhance communication between the agency, Medicare Advantage plans with prescription drug plans, stand-alone drug plans and Medicare Drug Integrity Contractors.
- 09/18/18--09:36: VA will open bidding for VistA EHR support, maintenance
- 09/20/18--09:24: Consumerism focus and global market insights are key to innovation
- 09/26/18--05:54: What innovation looks like at a large academic medical center
- 09/26/18--06:07: Maintaining data integrity during EHR migration
- 09/27/18--08:05: Checklist: Moving innovation projects from pilot to production
- First, "The Owner’s Manual," requires extensive documentation – slides, spreadsheets, etc. – to enumerate the project's value and instruct others on how to embrace it, he said, and "works best when there is no more ambiguity left in the challenge, when the project is ready for implementation by technical teams," he said.
- Second, "The Architect," occurs when a leader from another department "embeds" with the innovation team and "then acts as a connector, knowing all of the avenues already explored and all of the learning gained."
- Third, "The Ambassadors," also depends on teams embedded in each stage of the innovation, helping "ensure that no learning is lost and that each phase of work is designed to feed smoothly into the next." Such a strategy not only helps those who will be adopting the innovation, but helps the innovators have a better "awareness of what downstream teams need most."
- Fourth, "The Hive," centers around multidisciplinary teams that "tackle challenges across the initiative’s life cycle," and works best when innovation teams comprise "people from every major function and discipline" of a given organization. Think, for instance, of a pop health innovation pilot developed by clinicians, IT teams, data scientists, case managers, etc.
Elliott Management may wind up buying athenahealth after its long and pressure-packed courtship, given that other potential buyers, including Cerner and UnitedHealthcare, are reportedly not interested, according to the New York Post.
Elliott has teamed with Bain Capital, which owns Waystar, another healthcare technology company. The two private equity firms may now be frontrunners to buy the Watertown, Massachusetts-based cloud developer, which is valued at $6 billion, the report said.
Should the company be sold with the help of former CEO Jonathan Bush, he would receive $4.8 million, according to an athenahealth filing with the Securities and Exchange Commission.
Paul Singer’s Elliott Management already owns 9 percent of athenahealth’s stock and offered as much as $7 billion in a buyout offer earlier this year. In May, Elliott Management sent a letter to the board of directors to acquire athenahealth for $160 per share in cash.
That letter said the investment community agreed athenahealth has struggled financially and should explore a sale.
When Bush stepped down from the company he founded in June, following reports of sexual misconduct and domestic abuse, athenahealth said it would consider all strategic alternatives, including a sale, merger or other action.
Chairman of the Board Jeffrey Immelt was appointed as the company’s executive chairman on June 6, the same day as Bush’s departure.
Major electronic health record systems vendors are pretty innovative companies when it comes to keeping their products up to date with the changing requirements of delivering healthcare at health systems, hospitals and group practices.
But there is only so much big companies can do, and further, sometimes the perspective from an innovative upstart developer can shed light on new features and processes not previously considered.
This is why EHR vendors like Epic, Cerner and Allscripts in recent years have opened their products to third parties in the form of app stores, where smaller IT players can create and offer apps that integrate easily with the respective EHRs, performing tasks that the EHR alone does not offer.
We checked in with executives at each of the vendors to get a glimpse inside their programs and learn about favorite examples of third-party developers.
Epic’s App Orchard
Epic President Carl Dvorak said his company has always supported its customer community and other software vendors they work with in achieving successful integration and innovation. But in recent years, the EHR giant has taken new steps to foster innovation.
“Four years ago, we published Open.Epic to communicate our platform’s interoperability and innovation capabilities to the industry,” Dvorak said. “Open.Epic has been an excellent resource for the industry and us, helping developers and our community learn the many ways they can integrate their software with ours, and continue our work together investing time, money and resources to create and advance these standards.”
With the growth of the FHIR standard, Open.Epic also has become a platform for consumer app developers to connect their software to Epic systems, he added.
Last year, Epic launched what it dubbed its App Orchard. With App Orchard, Epic is cultivating hundreds of new relationships with developers around the world, many of them smaller organizations and entrepreneurs.
“For this group in particular, the App Orchard marketplace offers a low-cost entrée into a very large community of innovators and healthcare leaders,” Dvorak said. “Through this app developer program, we provide developers more than 540 APIs and data models, sandboxes, testing and demo tools, and technical, training, networking and marketing services to support and enable their companies and them to build products, services and businesses on our platform.”
Epic built App Orchard to accelerate the delivery and adoption of innovation within its community and across the industry, he added.
Allscripts Developer Program
Tina Joros, general manager and vice president of the Allscripts open business unit, said the vendor has supported third-party development and innovation via APIs on its platform for more than 11 years.
Clients have historically had the ability to use these same APIs for their own internal development. She said it was a natural extension to open that further to third parties so that integration could be consistent no matter which entity was building out new innovations.
Joros said that in 2011, Allscripts formalized the business side of what is now called the Allscripts Developer Program. That involved establishing a way for third-parties to apply and join, offering standards contracts and developer resources such as documentation, testing processes and a marketing website to promote the apps.
“The standardization of the process for gaining access to APIs along with the reusable nature of the functionality we support allows us to scale to allow thousands of developers to take advantage of our technology and the ability to bidirectionally exchange data with Allscripts solutions,” she added.
Cerner Open Developer Experience
Cerner’s motivation with Code, short for Cerner Open Developer Experience, is an open ecosystem where the industry works together to solve for health system and consumer needs alike, said John Gresham, senior vice president, DeviceWorks and interoperability, at Cerner.
“Cerner Open Developer Experience encourages innovators and developers in this space to develop apps that work across existing EHRs to advance digital healthcare, how it’s delivered, and ultimately improve interoperability and ease data sharing,” he explained. “App developers are revolutionizing the way we live and interact with the digital world, and healthcare is no different.”
Early health app success stories
Each of the EHR vendor executives have stories to tell about apps in their app marketplaces that have fostered innovation in the health IT space. Epic’s Dvorak points to an app called Krames On FHIR by The StayWell Company.
“StayWell has provided our mutual customers with patient education materials for years,” Dvorak said. “Clinicians are able to access the materials within their Epic workflows, assign the educational materials to patients, and print them to send home with the patient when they leave the healthcare facility.”
Through Epic’s App Orchard, StayWell offers a SMART on FHIR app that enables clinicians and patients an interactive, online experience including educational videos, in addition to traditional paper handouts. Also, as StayWell updates its content on a regular basis, it is able to more quickly deliver updates to clinicians and patients.
Gresham of Cerner singled out an app developer called ePreop. Health systems and physicians can solve common problems seen in the operating room every day, reduce waste and improve patient outcomes with the help of apps like ePreop, a third-party app provider, he said.
“Their apps AnesthesiaValet and SurgicalValet help health systems solve for communication gaps that can occur between physicians and anesthesiologist and support physicians in their surgical workflows,” he explained. “Through this app, errors and inefficiencies in orders can be identified by physicians, verifying the information entered into the EHR. From patient intake to readmission prevention, apps like these can simplify the surgical experience.”
Collaboration between health IT companies, third-party app developers and health systems can reduce inefficiencies in the clinical process, seize opportunities for improvement in care delivery, and even save lives, Gresham said. Using open platforms, open code and APIs accelerates the process of discovering new and innovative technologies that benefit the health and care of each person.
When it comes to innovative apps in the Allscripts app marketplace, Joros raises up Relaymed as exemplary.
“A great example of a solution that saves time and money is Relaymed, which sends test results instantly and automatically from devices to an EHR,” she said. “Last year, this app processed 1,500 lab results saving 5,000 hours of time for Allscripts clients – and that’s just time without counting the human error eliminated.”
Nor does it include potential lost revenue from billing of test results, she added. On average, manual entry of this data results in estimated lost test billing revenues of up to 20 percent, since not all tests are entered into the EHR, she explained.
EHR app stores: What the future holds
Moving forward, the EHR companies plan to continue to use their app marketplaces, among other strategies, to further EHR innovation.
“We are constantly engaging with the start-up community and organizations that are supporting health technology innovators like MATTER in Chicago and the Center for Digital Innovation in Israel to find the best new breakthrough technology for our clients first,” Joros said. “In 2017, we evolved our program to make it easier than ever to sign up for access so developers can click through an online agreement with zero upfront costs to have access to our API documentation and build out a prototype on our Developer Portal.”
Being transparent about the costs of connecting with Allscripts when a developer is ready to go to market and the functionality that is available is the company’s way of making it easier for developers to evaluate the time and effort it will take to build integration and support Allscripts clients using an integrated solution, she added.
“It’s not just the technology, it’s also what we are doing to encourage third parties to build apps that advance healthcare,” Cerner’s Gresham said. “It’s about the ways in which we approach app developers’ access to APIs via robust documentation, an open sandbox to build and test, and development support from our engineering community along the way.”
As part of the Code experience, Cerner dedicates energy and effort to developers’ success and continually looks for ways to improve their experience, he added.
“Today we provide a set of app validation services that drive quality apps into our marketplace, giving our health system clients peace of mind that the app has been validated prior to purchasing and implementing within their organization,” he said. “Additionally, we will continue to invest in a cloud-based API model that enables developers to build once and scale repeatedly to help reduce cost and complexity for health systems, speeding the time to innovation and deployment.”
The path ahead for Cerner is focused on continuing to advance its APIs and their capabilities, he said.
As for Epic, Dvorak said the App Orchard enhances the company’s suite of software, content and services by connecting its community to vendors that fulfill needs outside of Epic’s wheelhouse.
“As we work with other vendors, our teams identify opportunities for Epic to enhance integration,” he said. “For example, several of our newest product teams are looking to third parties to provide evidence-based clinical content. App Orchard provides our teams a platform to engage with other vendors as much as it provides those vendors a platform to engage with us and our customers.”
Epic looks forward to continually growing its integration and innovation technologies and services, he added.
“Through conversations, webinars and our annual conferences, our App Orchard members and customers contribute to our future direction,” Dvorak concluded. “They share their short-term needs and their long-term vision with us, and we incorporate their feedback into our platform, APIs and services.”
Focus on Innovation
In September, we take a deep dive into the cutting-edge development and disruption of healthcare innovation.
Cerner President Zane Burke, who first joined the company in 1996 and held several executive roles there before being named president, will step down on Nov. 2.
John Peterzalek, Cerner's executive vice president of worldwide client relationships, will take on Burke’s responsibilities, with the title of Chief Client Officer, the company said.
Over his two-decades at Cerner, Burke had a range of executive positions, ranging from sales and finance to technology implementation and support.
He was named president five years ago, reporting to Cerner founder and CEO Neal Patterson, who died in 2017. Brent Shafer, former CEO of Philips North America, was named CEO of Cerner early this year.
In recent years at Cerner, Burke was instrumental in helping the company win two massive electronic health record modernization contracts, from the Departments of Defense and Veterans Affairs.
In addition to helping grow the company's client base, he's also helped innovate its technology, whether it's by partnering with Apple to help move the needle on patient engagement and interoperability or touting the value of open APIs, a focus on consumerism or more innovative strategies for revenue cycle management.
"We thank Zane for his contributions to Cerner across more than two decades," said Shafer in a statement. "Zane leaves the company with a strong client focus and commitment to continued innovation, partnership and sustainable growth deeply ingrained in our culture and leadership philosophy."
Burke added that is he pleased with the disruptive accomplishments and positive change Cerner and its clients have achieved.
"Complex and evolving challenges remain, and Cerner is positioned to continue innovating for the good of consumers and health care providers," Burke said.
This past week, the Kansas City Business Journal reported that Burke had exercised options to sell almost $10 million in company stock.
Imagine knowing, in real time, whether a patient will suffer a surgical infection as a surgeon closes up a wound. That's the kind of clinical situation that machine learning is enabling at the University of Iowa Hospitals & Clinics.
To date, the health system's innovation with AI analytics has led to a 74 percent reduction in surgical site infection over a three-year period, which at scale is a $1.2 million cost savings – not including savings from value-based purchasing because of the reduced surgical site infection rate.
Iowa’s work with comes as more and more hospitals and tech vendors are undertaking innovative initiatives with machine learning and artificial intelligence. Johns Hopkins for instance, is using deep learning to improve how it handles pancreatic cancer and Amazon Web Services is harnessing machine learning to enable customers to better treat depression.
Co-developing machine learning
The university is co-developing the machine learning technology with vendor DASH Analytics. The system is called the DASH Analytics High-Definition Care Platform, or HDCP. Its proprietary design uses machine learning as it provides valuable data, metrics and decision support at critical moments during the point-of-care timeline.
HDCP, the university said, helps lower the rate of surgical infections, reduces the risk of requiring a blood transfusion during surgery, saves lives from brain failure and saves lives from unrecognized sepsis.
The technology combines several features, said John Cromwell, MD, associate chief medical officer and director of surgical quality and safety at the University of Iowa Hospitals & Clinics.
"The system uses curated knowledge of where and when specific critical decisions that drive outcomes are being made by providers for numerous clinical conditions where there is massive room for improvement," he explained. "It is a machine learning system that integrates with the EHR using industry-standard and vendor-specific APIs and in real time measures individual patient risks and evaluates appropriate best practice based upon these risks."
With those two features, HDCP integrates decision support within the provider's EHR workflow, and it generates feedback on how their use of the data changes their patient's outcomes, reinforcing high-value practices, he said.
The system works silently in the background, monitoring for specific points in patient care where decision support may improve patient outcomes.
At that point in time, the decision support becomes visible to the clinician or other front-line provider within their usual workflows in the EHR. It will present them with the specific risk for their specific patient along with actions to potentially mitigate that risk.
"The risks are assessed by using best-in-class machine learning algorithms that use both real-time and historical data on individual patients," Cromwell said. "These risk models are calibrated specifically to patients in each individual hospital using the platform."
Here's how it works
The surgical site infection reduction module in HDCP is integrated within the World Health Organization Surgical Safety Checklist that virtually all hospitals use during surgery. The module is activated near the completion of a surgery as the circulating nurse is going through his or her routine closing checks.
At the time of module activation, real-time data from the EHR such as the surgeon, case duration or estimated blood loss flows into the platform and is combined with historical data on the patient. All of this data then flows into the surgical site infection prediction model.
"The machine learning model calculates the infection risk and links this risk to specific interventions that the surgeon may take at the time of wound closure to reduce the infection risk," Cromwell explained. "The risk information and possible interventions are then presented in an interactive interface back to the nurse at her workstation – the whole process takes mere seconds to complete – who then delivers the information to the surgeon."
Using a single click, the nurse records whether the surgeon used the decision support recommendations. Ultimately the patient's outcome with respect to surgical site infection is returned to the platform and used to generate an aggregate report for the surgeon regarding his or her outcomes when recommendations were or were not used, thus reinforcing the use of appropriate decisions.
"It is very difficult for surgeons to integrate the information necessary to determine whether a patient is at high risk for a surgical site infection," Cromwell said. "There are certainly obvious cases where there is a break in technique, contamination, or very high-risk patient factors, but these are the minority of the cases."
There are interventions that can be done at the time of wound closure, but these can be costly or invasive. Would one do these interventions to 100 percent of patients if only a fraction can actually get a surgical site infection?
"Selectively using these interventions in patients where it is warranted by objective markers of risk maximize the therapeutic effect, while minimizing the cost and potential risks to patients," Cromwell explained. "In this case, we were able to selectively use negative pressure wound therapy on patients with markers of high risk to achieve the 74 percent reduction. Without the system, we could not have known objectively which patients to use this costly therapy on."
Ultimately, machine learning is critical for integrating hundreds or thousands of variables for individual patients in order to objectively measure risk, he added.
"Integrating such massive amounts of information that is impossible for any individual caregiver to perform," said Cromwell. "And no matter how much experience one has, the exponential increase in medical knowledge makes it impossible for a caregiver to assimilate all of the data necessary to consistently apply best practices in every situation."
A systematic approach to mitigating adverse outcomes or complications requires that one systematically identify the risks, he added. Machine learning algorithms, with few exceptions, are able to do this much more effectively than humans on a consistent basis, he said.
"This removes the variation in risk assessment that one may get between different physicians," he said. "Once a provider has an objective assessment of risk, then they may move on to mitigating that risk. When best practices are known and supported by data, machine learning can identify which patients these best practices should be applied to, in a consistent manner. By approaching risks objectively and systematically, we can have an effect greater than any pharmaceutical can provide."
Join us to hear how two Davies Award-winning organizations navigated the intersection between what they are achieving through health IT optimization and the policy implications of their working environments. Discover how to leverage EHR tools to increase communication and patient satisfaction scores while decreasing office visits, as well as how to leverage analytics to change opioid prescribing behavior.
Oakland, California-based Alameda Health System has named its new chief information officer. Mark Amey will relocate to the Bay Area from San Diego, where he was most recently associate CIO at University of California San Diego Health.
Alameda Health appointed Amey in the same week that Sanford Health named former VA Secretary David Shulkin, MD, as its chief innovation officer.
Much like Shulkin, Amey brings considerable familiarity with electronic health record implementations. Alameda cited its work to roll out a $200 million Epic EHR across the five-hospital public health system as among the reasons it brought Amey onboard.
Amey has been working in health IT for more than two decades. Before his stint at UC San Diego, he served as Chief Technology Officer during another Epic rollout at Lucile Packard Children’s Hospital-Stanford Health. Prior to that, he also held CIO positions at University of Southern California Health, Ascension Health and Adventist Health.
In San Diego, his day-to day responsibilities included oversight of its infrastructure teams, the project management office and security operations.
It was at UCSD that Amey helped transition its on-premise Epic system to a hosted cloud model. The mover not only helped the health system be more agile and maintain disaster recovery capabilities, he explained at the time, but "by creating greater operational efficiencies, we can invest more time and resources in patient care."
Other areas of expertise include management of outsourced IT vendors, conversion of services to in-house operations and more.
"I am excited to join Alameda Health System at this pivotal time in the history of the organization," said Amey. "Having gone through similar projects in the past, I know this implementation will transform the care we provide, including the exchange of information and communications with patients and medical colleagues."
Alameda Health partners with five other health systems in the Bay Area on an interoperability project designed to reduce emergency department usage but also boost the ED care that is delivered. With its new Epic rollout, it's hoping to spur easier data sharing among its own five hospitals.
"Mark’s in-depth knowledge and impressive experience align with the future direction of Alameda Health System," said Alameda's CEO Delvecchio Finley in a statement. "As CIO, we are confident he will guide the organization through a smooth transition to electronic health records that will enhance our commitment to serve our patients with highest-quality care."
One unintended consequence of the landmark HITECH Act of 2009 is the historic number of assaults by cybercriminals on the healthcare industry. The impact has taken multiple forms, including system and operations downtime, patient care disruptions, and dramatic financial losses. Yet legacy antivirus security solutions do not take into consideration several critical industry dynamics.
Glen Tullman has served as the CEO of a major EHR vendor and the founder of a startup app maker focused initially on diabetes.
That background gives him a unique insight into the possibilities and constraints of each. For our Focus on Innovation, I spoke with Tullman about the foundation EHRs have created for the future of digital health, what to expect next from Livongo, and where he expects next-gen innovations to come from.
Q: You formerly ran Allscripts and now lead Livongo. Given that perspective, what’s your take on the innovation happening in so many corners of healthcare right now?
A: EHRs are fundamentally data repositories, so what do you need to do? You need to make them much easier for physicians to use on the front-end. On the back-end a lot of companies like IBM Watson and smaller startups are saying ‘we’ll take the data from the EHR and analyze it to give you real feedback on how to provide better care.’ But EHR vendors aren’t doing any of that innovation.
Q: We are seeing EHR vendors take steps to open their platforms to third-party developers and enable them to drive some of that innovation but is that the answer?
A: EHRs were an important step to get things digitized but they have not realized the promise of making it easier for physicians to deliver care and they haven’t been connected to each other. Why not? Technology-wise, they could be connected.
Q: Well, there’s a lot of innovation happening in healthcare and much of has little to with EHRs. Where is it all going?
A: The future of healthcare is not about big software systems in hospitals. That’s important but healthcare today is about how we empower people with chronic conditions, how we empower those people with software and technology to make it easier to be happier and healthier. Everything people can rip out of a hospital they’re ripping out of a hospital. Surgery centers, urgent care.
Q: In which case, what’s next for Livongo?
A: We’re going to release a cellular-enabled blood pressure monitor so we have hypertension data and give people real-time feedback outside the doctor’s office because 24 percent of people on meds actually white coat hypertension instead of high blood pressure. Imagine if we could get them to check their blood pressure at home versus in the doctor’s office? It’s available now but the official release will happen at Health 2.0.
Q: And what about the broader industry, not just Livongo?
A: We’re going to see a lot of innovation. The world we’re talking about, tons of activity in digital health, making people smarter, helping them navigate the complex world of healthcare, making payments easier — that’s where the innovation is going to come from.
Focus on Innovation
In September, we take a deep dive into the cutting-edge development and disruption of healthcare innovation.
The Interagency Program Office (IPO) has not fulfilled its legal mandate to be the single point of accountability between the Department of Defense and Department of Veterans Affairs interoperability efforts. But both officials and lawmakers can’t decide who should reconcile the differences.
The inaugural House Veterans Affairs Subcommittee on Technology Modernization hearing, held on Thursday, revealed, not surprisingly, governance and accountability are still major points of contention for the project.
Government Accountability Office Director of Management Issues Carol Harris testified that while the VA has signed the contract with Cerner, created a program management office and drafted high-level governance plans -- program officials haven’t designated “what role, if any, IPO is to have in the governance process.”
Rep. Jim Banks, R-Indiana, supported Harris, remarking that the IPO is “one of the few aspects of EHR modernization mandated by law.” He also stressed IPO’s governance role in the projects was not only important -- but permanent.
The departments need to clarify the IPO’s powers, which was established in 2008 to not only oversee the initial EHR collaboration -- it gave them authority to resolve these differences, said Banks.
“My hope is DoD and VA will hash out what that looks like and come to mutual agreement,” Banks said. “I am willing to give them additional time to do that, but I will not wait forever.”
GAO is recommending the VA clearly outline the role IPO will have over the EHR project, specifically around governance, as “focusing on a single point of accountability is critical in moving forward to make sure that interoperability is functional,” said Harris.
But the VA Office of EHR Modernization Office’s acting Chief Information Officer John Windom told the committee that he doesn’t believe IPO has any decision-making authority of his office.
And IPO Director Lauren Thompson pointed out that her office isn’t equipped to be the single point of accountability for VA-EHR interoperability, citing a lack of authority, resources and staff.
“At this point in time, we do not have the decision-making authority,” said Thompson.
But Harris continued to press that the law makes IPO the “single point of accountability, so that would include responsibility, authority and decision-making.” In fact, the testimonies of both Windom and Thompson are in conflict with the statute’s expectations.
Further, Harris stressed that both DoD and VA have ignored GAO advice over the years on empowering the IPO. The role needs to be clearly defined, such as through Congress, which could relieve the office of its legal responsibilities.
“If the IPO continues the way that it is operating today, we are going to continue to have dysfunction in moving forward,” Harris said.
Discussions on better governance policies are ongoing, Windom testified. The conversations are overlapping with the VA rollout of its Cerner EHR. VA and DoD continue to work through the data sharing roles at the agencies, as well.
Thompson proposed governance should be broken down into three boards. One, a functional governance board, would handle disputes among clinicians and other healthcare employees. Two, a technology-focused governance board, would have the same function but for purely tech issues.
The final board would be solely focused on decision-making, designed to resolve problems the other two boards could not, said Thompson.
But Windom quickly countered Thompson’s idea, and said those low-ranking disputes could be resolved on the ground -- without having to involve “high-ranking staff members.”
“I can't impress upon the committee enough that governance has to be successful at the lowest possible level,” sad Windom. “Things can’t rise to the superior level on every matter.”
Harris agreed: With that many boards involved, accountability is “diffused so when the wheels fall off the bus you can’t point to a single entity… When everyone is responsible, no one is responsible.”
In the end, no clear decision was made at the hearing. Rep. Scott Peters, D-California, said the issue may need to be resolved by either Congress or the president, as the single point won’t be created without help.
Indeed, VA has struggled with both maintaining leadership and with governance issues for the past year. Since the dismissal of former VA Secretary David Shulkin, MD in March, at least 42 senior staffers have left the VA. The most recent came from the EHR project office itself, with the departure of its CHIO Genevieve Morris and CMO.
VA officials continue to double down on their projected 2020 go-live of its own pilot EHRs in the Pacific Northwest, designed to follow the DoD rollout. But GAO may also be investigating the DoD project, after an audit deemed the new system “not operationally suitable.”
The ongoing saga of athenahealth and Elliott Management continues. Shares of the cloud-based health IT company fell sharply Tuesday morning on news that the hedge fund – which has recently been seen as the most likely candidate to acquire the company after a long and contentious courtship – has reportedly recoiled from the $160 share price.
While activist investor Paul Singer may finally be throwing in the towel after many months of pressure on the Watertown, Massachusetts company, he may also simply be angling for a lower price. Reports earlier this month, in fact, indicated that EHR rival Cerner and insurer UnitedHealthcare are not interested in athenahealth.
Now, athenahealth seems willing to be patient and weigh its options, having extended the due date for a final bid by 10 days, according to the New York Post.
Elliott Management had indicated its willingness to pay the $160 share price, a total of some $6.9 billion, for the company in May.
But by June – when athenahealth founder and CEO Jonathan Bush was forced to step down after allegations of past domestic violence – at least one Wall Street observer wondered whether the sale process might eventually drag on so long that Elliott would rescind its offer, likely knocking the share price back down to the $135-$140 range.
With a rare near-unanimous vote, the United States Senate passed The Opioid Crisis Response Act of 2018 on Monday evening. It's a massive bill comprising a wide array of proposals drawn from five Senate committees, and has many implications for the use and funding of health IT.
Senate Majority Leader Mitch McConnell, R-Kentucky, called the bill – drawn up using input from more than 70 senators and passed by 99-1 vote – a "landmark" piece of legislation meant to combat the nationwide opioid epidemic from all angles.
The legislation comes amid an ongoing opioid crisis in the U.S. as policymakers and technology vendors are working to address the issue, while hospitals are piloting apps to find blindspots in prescription drug monitoring programs and using mobile technologies to write fewer prescriptions.
It contains funding for stopping the flow of illegal opioids from other countries, and for supporting local programs for prevention, treatment and recovery.
The bill also seeks to spur research and development of new non-addictive painkillers and stem "doctor shopping" by boosting prescription drug monitoring programs.
It also has funds to give behavioral and mental health providers the tools they need to offer treatment and recovery – including potential electronic health record incentives – and for hospitals to better care for infants with neonatal abstinence syndrome.
The legislation's sponsor, Senate HELP Committee Chairman Lamar Alexander, R-Tennessee, said he is working to combine the Senate bill and a similar House version passed in June "into an even stronger law to fight the nation’s worst public health crisis, and there is a bipartisan sense of urgency to send the bill to the President quickly."
The Senate bill contains many new proposals specifically related to information technology. Among them, it would:
Opioid Crisis: Tech fights epidemic
Learn how tech is being used to battle abuse.
The U.S. Department of Veterans Affairs modified its request for information on Monday, with plans to open bidding for a vendor to maintain and support its legacy VistA EHR architecture and imaging operations for the next five years.
According to the amended RFI, the agency plans to submit request for proposals on Sept. 21 through the General Service Administration’s IT Schedule. VA will seek “technical, managerial and administrative services” that will include “engineering support and engineering changes, updates, repairs” for VistA.
The vendor will also need to provide the necessary technology, while maintaining the system and providing help desk and operations support. The contractor will also need to deliver monthly progress reports that outline all required work during the reporting period, including any problems and how they were resolved.
“Due to the mission critical nature of the VistA and VistA imaging systems, VA’s objective is to ensure these systems are operational and accessible without interruption,” the draft performance plan stated. The contractor will need to ensure VistA remains in a “state of readiness and operation.”
Currently, the VA is developing a new Cerner EHR system to align with the Department of Defense. The RFI is not surprising, given VA officials have continually stressed that VistA can’t just be shut off and will need to be maintained throughout the 10-year Cerner rollout.
There are over 130 versions of VistA operating at more than 140 sites, and former VA Secretary Shulkin told Congress in February that VistA must be maintained for the duration of the Cerner project. Congress expressed concerned, both that the planned $10 billion budget does not include VistA maintenance and that it may not be possible to turn off the legacy system.
Interoperability: There’s a lot happening right now. FHIR, as in Fast Healthcare Interoperability Resources. Open APIs. Blue Button 2.0. Carequality and CommonWell reaching a milestone this summer in terms of exchanging Continuity of Care Documents.
At the same time, however, a thorny reality persists: The average hospital has 16 disparate EMRs in place among its affiliated outpatient practices. Look more broadly at integrated health systems, and that number bumps up to 18.
So where is it all going? And what will it take to get to the point where interoperability, though perhaps not 100 percent solved, will be a less pressing issue for hospitals, EHR vendors and tech startups?
I spoke with HIMSS Chief Technology and Innovation Officer Steve Wretling about what the industry needs to achieve interoperability, his advice to aspiring entrepreneurs and the innovation that has surprised him most.
Q. You’ve been working on the tech side of healthcare long enough to have seen considerable changes amid the growing pains. What makes you the most excited right now about the future?
A. The unpredictability itself is really exciting. We’re in a data revolution time period where digital information and technology is opening many avenues to innovation on data that have not been there before. What’s also exciting is that one model is not going to prevail. The old models require standardization of many processes but digital health frees up the creation of completely new processes – more appropriate than a single model. The promise of innovation will allow the ecosystem to shift from treating a sick patient to a person seeking health.
Q. Speaking of excitement and unpredictability, let’s talk a bit about data interoperability.
A. There’s so much good happening and we could leverage it so much more. When the JASON task force published its Robust Health Data Infrastructure report in 2014 there was a rough draft of an architecture and what took hold was the APIs and that’s great, however, an architecture needs to be developed to see interoperability beyond APIs.
Q. Interesting, with all the buzz about open data, APIs and FHIR one does not hear as much about the need for an architecture. Where is this all headed and what should hospital IT shops and the startups looking to win them as customers be doing now to prepare?
A. What’s really clear is that API-based information exchange is finally taking root in healthcare and I believe version 4 of FHIR will be a normative standard. If you’re on version 2 and I’m on version 3, I can’t necessarily work with your FHIR. 4 will be a true go-forward standard. So hospitals and services providers should start demanding the types of apps they need to fit into their workflow. The emergence of SMART and SMART on FHIR will give them a second chance to build systems of the 21st century instead of just an EHR approach. Startups should be looking at APIs as the glue that will connect disparate systems.
Q. September being the HIMSS month to Focus on Innovation, of course, what advice would you give aspiring entrepreneurs, dreamers, developers?
A. I’d say look at the landscape: Healthcare is consuming 17 percent of our GDP. New models are urgently needed to provide better care at lower costs. The promise of health IT is beginning to be realized but there are so many great opportunities. Think outside the app and services you’re trying to create because silos are just not going to prevail anymore. Understand the adjacencies, that will set you dramatically apart, and whatever you do it must be evidence-based so find the best hospitals to innovate with and partner.
Q. Looking back at the course of your career, what innovation – in healthcare or elsewhere – has surprised you the most? Why?
A. What surprises me the most is the enigma of the smartphone. It has become a part of the person, a part of our culture more than I ever thought it would and the ability for it as a comprehensive platform to include features and innovate has stood the test of a decade. From a tech perspective, that is incredible – and it has no signs of slowing down but, instead, morphing into other things, like a phone or sensor on your wrist.
Focus on Innovation
In September, we take a deep dive into the cutting-edge development and disruption of healthcare innovation.
In his role as Applied Innovation Manager in the office of the Chief Technology & Innovation Officer at HIMSS, Ian Hoffberg has a front row seat for the dizzying change going on in healthcare around the world.
In fact, one metaphor he uses for his day-to-day work – keeping plates spinning in the air – gives a sense of the thrilling momentum he feels happening across so many different facets of healthcare, as information and technology both evolve.
As applied innovation manager, Hoffberg works with the 18-member HIMSS Innovation Committee, a group comprising forward thinking execs and leaders, from across the healthcare and technology industries, that helps shape the ways innovation content and strategy is developed at the global not-for-profit.
He also helps manage the larger but similarly diverse HIMSS Innovation Community, some 10,000 members strong, which gathers quarterly to share ideas about how they're fostering new ways to drive quality outcomes, lower costs and improve the patient experience.
It's a big tent, but Hoffberg said it should be even bigger. Because really, if you're a HIMSS member at all, "you follow innovation," he said. "That's why you're here. You want to learn what's the next trend, the next solution to the challenges we face in healthcare. So, personally, I joke that all of HIMSS members should be considered HIMSS Innovation Community members."
As more and more Innovation Community members get up to speed with the massive changes that have been happening for the past decade-plus, the questions they're grappling with have matured into complex innovation how-tos, he said.
"How do you secure the funding? How do you do the scaling? How do you partner with third parties? How do you use APIs and open source technologies? We're exploring all these factors that help healthcare organizations innovate."
Innovation's steady evolution
Hoffberg has seen healthcare and health IT come a long way over the past two decades. It's where he's spent his entire career – starting in the 1990s, just out of college, at Memorial Sloan Kettering Cancer Center in New York. Even in those early days, innovation was bubbling up.
"That's where I first saw an EMR and point of order system: It was so revolutionary for the time – all built in-house, all built according to what the physicians needed," he said. "The biggest challenge was making sure people use it. Because it was a new technology. And one of the biggest challenges was just getting physicians to place their orders and for nurses to use the order system."
"We need to make sure that all of healthcare is firing on all cylinders and providing that high level of care. Healthcare isn't the same in a big city as it is in rural America."
Ian Hoffberg, Applied Innovation Manager at HIMSS
But when tools such as those were able to gain traction, "that's when I first saw technology making a huge impact in the daily application of healthcare, and providing of that higher-level care for the patients."
Next, Hoffberg worked at athenahealth, where he worked as a clinical operations senior analyst. In its medical records quality assurance department, "we were intercepting every fax that was going into the practice, manually entering all the important data fields," he said.
"You don't have enough time in the day to process that amount of work, so they started developing more in-house solutions to help properly manage the volume of data we were receiving," he explained. "It was fun to work with our QA team and our coders to develop a document recognition system: fine tuning what it is we were looking for and, again, providing higher-level care by reducing errors and using technology to get physicians those documents in a much faster and more reliable system."
New (and old) technologies must serve patients
From there, Hoffberg moved to the nonprofit side – first with a stint at the National eHealth Collaborative, focused on the consumer experience, and then to HIMSS.
It's there, even though his work focuses on all corners of the healthcare industry, that "the voice of the patient started ringing so loudly for me. And once you ring that bell, you can't unhear it," he said.
"Utilizing technology to care for the patient – in a way that the patient can use, and is of benefit to them, started changing the game," he explained. "We need to let the patient have a seat at the table, because they're the ones that are directly impacted by all the different apps and technologies coming out."
And, indeed, for the first time in recent years, it's become more and more apparent that consumer tech is pushing healthcare in directions it might previously have been reluctant to go.
"Technology is catching up to the point where it is surpassing the abilities of the healthcare industry," said Hoffberg. "The expectations have changed drastically in the past 10 years. The technology has provided an environment where we can no longer do business as usual."
And not only do we "need to use the technology that is out there," he added, "we need to use the tech we have in more efficient ways. Innovation is not just developing new, fabulous technology – it's also using current technology in a smarter fashion."
Need proof? Just look at any number of HIMSS Davies Award winners. "They take their EMRs, just tweak the dashboards ever so slightly and they're reducing sepsis, reducing readmission rates – they're using the technology in a new way to have it work for them and for the patient," he said.
International expansion fueling innovation
HIMSS itself has seen a "fundamental shift of agenda over the past year," Hoffberg pointed out. For instance, CEO Hal Wolf has reemphasized the vast international reach of the cause-based group and new Chief Technology and Innovation Officer Steve Wretling is pushing to further engage tech developers and innovators of all stripes, all over the world.
"How we're going to focus on innovation in healthcare is changing," Hoffberg explained. "HIMSS is a global enterprise. And what we need to do is partner more efficiently with our European partners, our partners in Asia and the Middle East, etc. So we can start sharing our stories more on a global scale."
After all, he said, "best practices we have here in America may be best for certain scenarios, but there are also partners in Europe who are approaching consumer engagement, for instance, in a different way and having more success with it. There are great success stories out there, and that's one of the things we're trying to work on with the HIMSS Innovation Committee – bringing more of a global, relevant content portfolio to the table for our members."
Toward that end, HIMSS will soon be releasing some new research to help hospitals and health systems better understand the organizational characteristics and attributes that are key to facilitating an innovation culture. That research, scheduled to be released this fall, can be used to help healthcare organizations assess their own innovation-readiness – and tap into other prescriptive innovation-related content and resources at HIMSS.
In the meantime Hoffberg, alongside with colleagues, Justin Gernot, vice president of HIMSS Healthbox, and Adam Culbertson, HIMSS Innovator in Residence, will be presenting a webinar, What Innovation Means to Healthcare and Why it Matters Today, on September 28.
Big players must help solve pain points for everyone
Right now, Hoffberg is still thinking about the patient experience. Specifically, not surprisingly, he's interested in how "these new big players on the healthcare scene, the Apples and the Googles, these big, consumer facing entities," will continue to reshape it.
"I think there's going to be a tremendous shift over the next five to 10 years," he explained. "You're going to see a run to keep up with the industry by a lot of health systems and providers to make sure they're providing that expected level of care moving forward."
And while Hoffberg is clearly bullish about innovation's forward momentum, he's also clear-eyed enough to realize that "we're going to have some failures."
But we're going to learn from those failures," he said, "and that's how we're going to build a bigger and better ecosystem to deliver healthcare for our patients, and create something that isn't too cumbersome for our physicians and nurse practitioners and our hospital staffs."
Earlier this year, Hoffberg broke his leg while skiing in Utah. After receiving treatment, he travelled home to Virginia – before moving, a few months later, to Texas.
"With the trail of my care plan, moving across the country and then back across a second time, you can see the inadequacies in the healthcare system," he said. "We talk about technology making a difference, but there are still a lot of pain points out there."
More and more, forward-thinking hospitals, health systems and tech vendors are coming up with new and creative ways of alleviating those pain points. But it's important that those innovations are distributed as far and wide as they can be.
"We need to make sure that all of healthcare is firing on all cylinders and providing that high level of care," said Hoffberg. "Healthcare isn't the same in a big city as it is in rural America. With more and more technologies coming out, we need to make sure that everyone is brought along for the ride and doesn't fall behind."
Focus on Innovation
The third major health system to win a HIMSS Davies Award over the past month is Durham, North Carolina-based Duke Health. Specifically, the award recognizes the health system for customizing its electronic health record to better serve standardized care processes for improved patient safety and post-surgical outcomes.
Duke Health joins Mercy, which earned its Davies for work fighting against the opioid crisis, Ochsner for arming clinicians with tools connected to its EHR that make them more effective in treating patients diabetes and hypertension, and TriHealth, which achieved it Davies for innovative population health management work.
Duke’s effort to reduce high readmission rates for post-surgical urinary tract infections, led by colorectal surgeon Julie Thacker MD, developed and put into place a standardized care process for patients who had had colectomies or removal of part of their large intestines.
Enhanced Recovery After Surgery, or ERAS, was the protocol Duke developed eight years ago to improve how those patients were managed during the pre-, peri- and post-operative period. Factors such as nutrition, activity and pain control were addressed, and sometimes adjust – ultimately leading to lower lengths of stay, fewer secondary complications and far fewer unnecessary readmissions.
In 2016, ERAS integrated into Duke Health's EHR, giving clinicians visual cues for patients' status, across the care continuum. With these prompts, caregivers could more easily spot patients on the protocol, boosting ERAS compliance across the process.
The near real-time reporting data also led to further outcomes improvements – notably a 50 percent reduction in readmission rates for colectomy patients.
In addition, the health system has "created a blueprint for reducing potential opioid dependency by leveraging IT to standardize patient recovery from surgery," said Jonathan French, senior director of quality and patient safety at HIMSS, in a statement. "The standardized patient care process for colorectal surgery empower periop nurses to order alternative pain management therapies for recovering surgical patients. This avoids unnecessarily exposing patients to opioid treatments, which lowers the risk for dependency."
In addition to the ERAS initiative, Duke Health was also recognized for two other innovative projects. One, an optical character recognition tool, allows computers to capture outside laboratory data discreetly into the EHR, by reading images such as faxes. The tool has led to 25 percent time savings in outside lab data capture.
The other, called the Care Redesign Program is a complex and longstanding initiative – five years and 17 different use cases – that aims to improve clinical integration of the EHR with operational processes toward improving quality, safety, efficiency and cost savings.
Jeff Ferranti, MD, chief information officer for Duke University Health System credits a "spirit of continual learning, teamwork, and ongoing process improvement" for gains such as those.
Big Data & Healthcare Analytics Forum
The Boston forum to focus on effective pop health management, AI and precision medicine Oct. 22-23.
UCHealth was having troubles with its prescription process – especially a wide variation in prescribing behaviors among providers, who often opted for medications that were not first-line guideline-recommended meds for a specific indication, weren't covered by the patient's insurance, weren't on the formulary or were too expensive for the patient.
Vendor RxRevu started implementing its SwiftRX tool at UCHealth in April 2016 with the goal of engaging prescribers with best practices for disease states involving antibiotics in the emergency department. One month later, RxRevu won a Colorado state-funded grant from the Office of Economic Development and International Trade to inform prescribing for at-risk congestive heart failure patients in primary care with evidence-based guidelines.
RxRevu began its work with UCHealth by deploying SwiftRX, which presents the prescriber with medication recommendations automatically when a diagnosis is entered in the electronic health record. This allows prescribers to save clicks in their workflow versus the standard order entry process in the EHR. Click reduction greatly reduces their time searching for the most optimal medication for their patients.
In June 2018, RxRevu launched SwiftRX with real-time patient-specific pharmacy benefit management data that allows the prescriber to check the patient's out-of-pocket cost and coverage status of any medication and immediately select the order.
Today, RxRevu has expanded its footprint by supporting prescribing guidance for roughly 80 percent of UCHealth's prescription decisions, and in the form of expansion initiatives across all of primary care and virtual care.
The market for electronic prescription and Rx decision support software is relatively large. Technology vendors include AdvancedMD, DrFirst, Imprivata, MDToolbox, Practice Fusion, RxNT and Surescripts. And most of the major EHR vendors offer e-prescribing and related functionality.
MEETING THE CHALLENGE
UCHealth uses Epic for its EHR. SwiftRx is not technically within Epic but is a separate system that appears to the clinician to be integrated in such a way that the provider behaves as though it is within their EHR workflow.
"SwiftRx functions by analyzing key data points from the patient's medical record within the EHR and recommends pharmacotherapy based on the provider's impression or diagnosis," said Richard Zane, MD, chief innovation officer at UCHealth.
"For example, if I diagnose pneumonia, the tool will recognize if I am treating community-acquired pneumonia, if the patient has comorbidities that affect the treatment of pneumonia, like emphysema, if the patient has allergies, and what the antibiogram for my hospital and region are," he said.
The system then recommends antibiotics and other medications like bronchodilators, antipyretics, steroids and so forth, if indicated, he added.
"Using the example above, the physician sees the patient as she normally would, makes a diagnosis of pneumonia, and clicks the SwiftRx tab in the discharge workflow," Zane explained. "SwiftRx will recommend the medications as first-line, second-line, etc., and note any allergies. The physician then clicks on the recommendations, and the physician's orders are automatically populated."
The physician signs them as usual, and they are sent electronically to the pharmacy; the prescriptions are recorded in the EHR. It's essentially easier for the physician – fewer clicks, easier workflow, less data to gather – and there is a significantly higher chance of getting the medications right the first time, he added.
"We will pair an engineer with a provider. If something doesn't work, is clunky or not intuitive, it gets fixed immediately, and the providers get feedback."
Richard Zane, MD, UCHealth
UCHealth today supports prescribing guidance for roughly 80 percent of the health system's prescription decisions. Further, prescriber acceptance of preferred medications within the RxRevu tool has increased from 44 percent at launch to
74 percent today.
"We have five universally unalterable guiding principles when working with technology partners who wish to co-develop clinical decision support, or clinical anything for that matter," Zane said.
First, whatever is designed must function within the provider's EHR workflow; second, the tool must be easier to use and not harder; third, there must be fewer clicks and not more; fourth, there can be no "force function," meaning no hard stops or many added steps to avoid the tool; and fifth, it has to work all the time, Zane explained.
"Essentially, the tool must be the path of least resistance,” he said. “We work on the premise that providers are smart, they all have smartphones and PCs, and that using and deploying a new clinical tool has to be as intuitive as downloading a new app."
The IT team essentially tells clinicians a tool exists and what it does, and asks them to try it twice. If they don't use it or like it, the team dives deep and deliberately into optimization and iteration.
"We will pair an engineer with a provider and iterate minute to minute and day to day," Zane explained. "If something doesn't work, is clunky or not intuitive, it gets fixed immediately, and the providers get feedback."
ADVICE FOR OTHERS
Zane said it's important to have a set of core guiding principles when deploying electronic clinical decision support.
"Ours are absolute and non-negotiable," he said, referring to the aforementioned five principles. "It must be bulletproof and accurate 100 percent of the time."
How do you ensure ease of access to patient records in a timely manner without compromising privacy? In this webinar, Nick Desai, CEO and Co-Founder of Heal, and Kevin Sheu, Director of Customer Identity Solutions at Okta, discuss the challenges of balancing patient control with data security.
For New Orleans-based Ochsner Health, innovation is an enterprise-wide effort.
"It's my job. We wake up every day and this is our mission – we're not getting pulled off on other short-term issues that are important in the day to day operation of the business,” said Ochsner physician Richard Milani, MD. “We're able to devote our energy full-time to this."
One instrumental way Ochsner leadership sought to support system-wide innovation, in fact, was to "produce a dedicated team toward that end," he said. "So instead of just paying it lip service, the CEO went out and said we're going to create a new role, Chief Clinical Transformation Officer, and invest resources into the whole process of innovation."
Milani knows better than anyone, since he is that CCTO, a role he's held since 2012. (He's worked at Ochsner for two decades as a clinical leader focused on cardiovascular diseases.)
innovationOchsner keeps health system focused
As CCTO, Milani is also medical director of innovationOchsner, or iO, a tech accelerator launched in 2015 whose laser focus on innovation has helped the health system stay ahead of the leading edge of healthcare technology.
Whether it's working as one of the three-dozen health systems to pilot Apple Health Records, making tweaks to its Epic system to help combat the opioid crisis, or winning (as it did this past month) a HIMSS Enterprise Davies Award, Ochsner is at the forefront of innovation, and iO is the engine driving it.
As one of the biggest independent academic medical centers in the U.S. and Louisiana’s largest health system, Ochsner's 30 hospitals and 80-plus health centers and urgent care facilities employ nearly 20,000 people, including 1,200 physicians.
The iO team, whose stated mission is to use "technology and data to create precision-focused, patient-centered solutions to keep patients healthier and providers more efficient," is small – just 30 or so people, Milani said. But its various innovations are deployed throughout the health system and have had large and lasting impacts.
For instance, some of the projects that helped Ochsner win its Davies Award were developed by the innovationOchsner team: three data-driven initiatives focused on improving care for hypertension, diabetes and obstetrics. iO created dashboards, EHR apps, remote patient monitoring tools and updates delivered to patient's MyChart portals to help guide interventions and encourage lifestyle changes.
The numbers so far tell the story: The Hypertension Digital Medicine project successfully controlled in 71 percent of previously uncontrolled patients within the first 90 days; Diabetes Digital Medicine was able to achieve a 1 percent drop in A1c levels and boost retinal exams; the Connected MOM app helped bring about a 30 percent reduction in the number of in-person routine obstetrical visits.
Beyond recognition at the executive level of the need for innovation, the creation of a dedicated team devoted to that mission has been key, said Milani.
"That's the first thing – recognition of the need, and the willingness to devote time, energy and resources toward it," he said. "To do this well, you need a dedicated team. This kind of stuff is difficult to do as a part-time side job, because you're always going to be pulled into the needs of your first job."
Through it all, the team stays focused on the big questions: "What are the cost drivers? What are the pain points? Where is the friction in the system? And how can we aim our energies at those and try to create efficiency and improve quality and safety?"
Even though iO is still a small team, it's getting bigger as the projects it's working on proliferate.
"We have groups focused on the hospital environment, we have folks aiming at the outpatient environment in terms of digital care. We have areas we focus on with regard to the process behind the scenes, how we manage it and use it – including artificial intelligence. How can we improve the patient experience? All of those domains."
How do those decisions get made? How does Ochsner decide on which clinical use cases are in need of innovation?
"It's really not a top-down strategy," said Milani. "It's not the CEO or CFO saying, 'Go fix this,' or anything like that. It really is sort of bubbling within the iO group. And a lot of it is just listening to the physicians and the nurses – and even the back office people, the business people. Hearing what the issues are, putting our heads together to say, 'What are the things we can do to make a difference? Is it something we can tackle? Is it going to have a high impact?"
Enterprise-wide innovation starts with early adopter testing group
The aim is for the innovations at iO to be "meaningful over a substantial portion of the organization or for a substantial portion of patients," he said. That's why the projects that get tackled are in areas such as hypertension and diabetes.
"Chronic diseases are responsible for 86 percent of the money spent in healthcare, and 70 percent of the deaths," said Milani. "Hypertension is the most prevalent disease in the United States. Diabetes is becoming one of the top two or three most prevalent and it's growing at a fast clip. We've got another project coming out this year with COPD. We're going after things that are high impact."
But in an organization as large as Ochsner, disseminating those innovations enterprise-wide, encouraging uptake of the tools and strategies the iO team creates can be a challenge.
"There's science behind how innovation is diffused across any company or entity," said Milani. "There's a wonderful book by Everett Rogers called Diffusion of Innovations, where he categorizes employees into different groups, based on their natural tendencies. Some people are early innovators or early adopters, some people are late adopters and some people are laggers -- they're not excited about change and they may even resist change."
At Ochsner, that means identifying early adopters in the primary care group, for example, and working with them at first to test emerging technologies and get their feedback, rather than having too many users involved.
"That's been one of the key elements in how we spread this. If they like it, and they adopt it, then they become the champions for spreading it among their brethren, so others who were more late adopters would begin to catch on,” Milani said. “And as we've been able to pick up momentum we've been able to show results.”
As evidence that the model works, Milani pointed to iO's hypertension and diabetes initiatives, which now have a 100 percent participation rate among primary care doctors.
"And they see the real value in it. But you couldn't just flip a switch on day one and start with 100 percent. You have to let them be comfortable with it, understand the value of it, understand how it works, get feedback from patients and from other doctors who were utilizing it, so they could say, 'Y'know, this is really good, I think I'll start using it.'"
Investing in key staff fosters success
Ochsner is clearly a leading light when it comes to innovation. Its size and scope mean it's more able to invest the staffing and resources to experiment with new approaches than many smaller health systems.
That said, there are lessons other providers can learn from successes like iO. For those hospitals serious about fostering a culture of innovation, "the principals that we've gone by still apply," said Milani.
To start, "these things are hard to do without leadership behind them. I report directly to the CEO, so I'm not having to go through 100 layers."
When it comes to creating innovation teams, "you don't have to have 30 people – you can have two people whose full-time job is to work on this. That's not a big investment, to start with one or two people. It's certainly doable. You could do that at a community hospital. You don't need to be a big health system to do those things."
Focus on Innovation
Nearly three years ago, PwC’s Health Research Institute dubbed 2016 the year of “merger mania” in healthcare. With so many shifts occurring across the industry, many health systems have looked to mergers and acquisitions to help them survive – and thrive – in a value-based care world.1 The trend continues to this day. In fact, earlier this year, PwC reported the announcement of more than 250 healthcare M&A deals in the second quarter of 2018 alone.2
But while scaling up in this manner has multiple advantages for health systems, it is not without challenges. One of the biggest is maintaining data integrity as organizations migrate data into a common electronic health record (EHR) platform.
There are many reasons why a given healthcare organization may need to migrate patient data from one EHR system to another – to provide a single system for multiple institutions in an M&A situation, to lower the costs involved with maintaining an outdated legacy system or to eliminate dangerous data siloes that interfere with clinical decision-making, just to start. But Rod Piechowski, Senior Director of Health Information Systems at HIMSS, said that healthcare organizations should not downplay the data integrity risks involved with such a move.
“One of the biggest challenges, which is also one of the most important elements of a successful migration, is developing a plan that properly addresses the scope of data that needs to be migrated, the order in which it should be done, and the amount of time that a quality migration can take,” he said.
The risks of poor planning
Putting the right plan in place requires a lot of forward thinking, as well as cooperation among different stakeholders across the enterprise, said Michelle Holmes, Chief Operation Officer at ECG Management Consultants. Too often, she maintained, those two factors are lacking in the pre-planning stages of the process – and this can significantly increase the risk of data integrity issues later.
“You can’t just assume that there’s going to be a one-to-one relationship between data types and fields and that everything will flow over accurately. You need to understand the implications of a mapping error can be quite significant, to both providers and patients,” she explained. This is why, she said, you can’t rely just on electronic migration processes. There needs to be a manual component, for example, clinical abstraction services, as well.
When critical information is lost or corrupted, it can affect the quality of patient care. Providers won’t have access to the data they need to guarantee patient safety. “You don’t want to lose or incorrectly map drug allergy information, for example. Patient safety issues open up a whole new world of liability,” said Piechowski.
But data integrity affects more than just patient safety, he cautioned. “If you’re migrating more than just clinical data, like scheduling and billing, you run the risk of business interruptions, revenue issues, and, in the long-term, problems with your reputation,” he said.
Taken together, these factors can negatively impact provider trust, patient satisfaction and the strength of the patient-provider relationship.
Strategies for success
Piechowski said that a strong data migration strategy starts with bringing the right people to the table to map out a workable plan of action. “When building a migration team, include a wide variety of people from many different areas within the organization, with a variety of skills,” he said. “You’ll need clinicians as well as technologists, revenue specialists and others.”
And even with the strongest migration strategy, it can be important to leverage external organizations, such as manual abstraction services to ensure the consistency and accuracy of clinical information that is being migrated across the system.
He argued that abstraction plays an important role as the migration team shapes your data migration plan, helping to build and refine the rules that will be used to preserve historical clinical data.
“Abstraction can really benefit a larger migration, especially if there are elements that must be converted that require clinical insight and decision-making in order to do a successful mapping, especially where patient safety is concerned,” he said.
Holmes added that organizations should not underestimate the need for quality assurance testing. “You need to put the time and resources in place to test, test and retest before every partial and full migration,” she said. “It’s also important to make sure you have ongoing quality assurance processes and manual abstraction processes to fill in for any information that may not have been migrated or may have been incorrectly migrated.” This is where an organization like a clinical abstraction service can be especially important to your migration strategy.
As with so many information technology initiatives, it’s better to have the right scaffolding in place from the start to ensure data integrity – and, ultimately, patient safety and satisfaction.
“Consider the impact of incorrect or incomplete information on future decision-making in a clinical encounter. The same is true of business-related data if it is being moved,” said Piechowski. “It’s better to do it correctly than to do it fast.”
1. Top Health Industry Issues of 2016: Thriving in the New Health Economy, PwC Health Research Institute, December 2015. https://www.pwc.com/us/en/health-industries/top-health-industry-issues/assets/2016-us-hri-top-issues.pdf
2. US Health Services Deals Insights: Q2 2018, PwC Health Research Institute, August 2018. https://www.pwc.com/us/en/health-industries/publications/assets/us-health-services-deals-insights-q2-2018.pdf
So, you've got an innovation initiative of the ground. You've come up with a use case to tackle, secured executive support, scrounged together a budget, and have made some encouraging headway in advancing the new technology in a pilot setting. Now it's time to scale it up and spread that ingenuity across the organization.
But how? Even the most exciting innovation project won't count for much if it's only used by a handful of hospital staff. The key is to get it to catch on and proliferate enterprise-wide, so even the most recalcitrant clinicians might see its value and embrace its transformative potential. Here's a checklist to help make that happen.
1. Have a sound strategy.
"Ad hoc innovation is not enough," said Adrian Zai, MD, director of research at Partners eCare earlier this year. It's crucial, he said, to align innovation initiatives to specific areas of need, and to be able to scale up promising programs when applicable.
"Formalizing your innovation strategy is critical," he said. To truly drive diffusion and uptake of new ideas, it's crucial to have "infrastructure that promotes innovation across your organization – otherwise, you're just hitting your head on the wall."
2. Understand different approaches to spreading knowledge.
In a recent article in Harvard Business Review, "How to Hand Off an Innovation Project from One Team to Another," Joe Brown, a portfolio director at IDEO, laid out the stakes: "If innovation projects are going to succeed, they’ll need to survive a handoff from an innovation team to an execution team," he said. "And every time you create a handoff, you risk dropping the baton."
Brown identified four basic strategies for how to handle those transitions, and said which you'll use will depend on the specific goals of your organization:
3. Know the importance of specific roles.
Simon Wardley, a researcher for the Leading Edge Forum, a think tank focused on bridging the gap between operational strategy and new technology, identified three personalities essential for evangelizing and eventually operationalizing new innovations: pioneers, settlers and town planners.
Pioneers are "able to explore never before discovered concepts, the uncharted land," he said. "Their type of innovation is what we call core research. They make future success possible" – even if their initial ideas don't always work right, or are baffling to new users.
Settlers "can turn the half baked thing into something useful for a larger audience," Wardley explained. "They build trust. They build understanding. They learn and refine the concept. They make the possible future actually happen. They turn the prototype into a product, make it manufacturable, listen to customers and turn it profitable."
And Town Planners, by leveraging economies of scale, "are able to take something and industrialize it," he said. "They build the platforms of the future and this requires immense skill. You trust what they build. They find ways to make things faster, better, smaller, more efficient, more economic and good enough. They build the services that pioneers build upon."
All three are important to spreading innovation, but it's just as important to understand which leaders a given organization fit which role – and ensure they're put in a position to fill it to their potential.
4. Assess any and all possibilities for automation.
One of the first orders of business when looking to scale up innovation is to "find every process you can automate," said Richard Milani, MD, chief clinical transformation officer at New Orleans-based Ochsner Health. "You have to do an inventory before you go pilot to scale: 'What things are we doing now are automatable?'"
It's important to be ready for the implications of big growth, Milani said. "Right now you might be saying, 'I can do this manually for these three use cases,'" he explained. "Well, those three use cases might be going to 3,000 use cases in a few months. You're not going to be able to keep up with a lot of those manual tasks. You're going to want to see what is automatable that is being done by humans today. And it's worth trying to put that in to test it, because when you scale, it's going to be tough to keep up.
"That's probably the single most important thing you need to do before you broaden it," he added. "Everything else sort of ties to that, because some of the sub-things are like interfaces, and 'is the technology bullet-proof, are you going to have resources to scale, all that sort of stuff."
5. Customize for your customers.
"One other important area is to be able to build in customization for physicians if that's possible," said Milani. "You may have a process that's one-size-fits all, but docs are not always one size fits all, and physicians like to be able to have their own preference settings. So even you and I might be using the same innovations, I might like it one way and you might like it a slightly different way."
It's key to be able to anticipate and "try to collect in advance what are the things physicians feel they need to control, to be able to modify it in whatever it is you're rolling out," he said. "See if you can try to create preference settings for some of those modifications. That's going to come up when you roll something out across a bigger area, and if you already have that figured out and built in, it just makes it go so much smoother."
6. Foster a collaborative spirit.
Real momentum can be accomplished by breaking down barriers to better diffuse the new ideas across the organization, said Partners' Adrian Zai. The most effective innovation depends on the "removal of artificial divides," he said.
Whether it's team-based care projects, new technology rollouts or complex, interdisciplinary approaches to population health management, healthcare improvements depend on healthy collaboration. So when looking to drive innovation, it's valuable to "promote interdisciplinary innovation teams," said Zai.
"There are still artificial divides that hinder innovation," such as between research and clinical roles, he added. But at Partners HealthCare, "we compartmentalize these two areas such that one has nothing to do white the other."
It's all done with the big goal in mind, he said: "Everything we do in innovation and research should trickle down into operations."
7. Be ready to show value.
"You want to be able to provide feedback, in a timely fashion, to the users," explained Ochsner’s Milani. "Is this working? Do they have a way of knowing it's working? What are the benefits?
"Whatever you're innovating, whoever the users are have to perceive value," he said. "You have to demonstrate value to the players in the system, whether it's patients or doctors or nurses. How are you showing them continuous value in an ongoing way. You need to provide that feedback. It could showing that your blood pressure is better controlled, or that there are fewer EHR clicks and you're saving time. Whatever the innovation is, you need to show it in a meaningful way, as feedback to the users. Otherwise, people won't use it."