The U.S. Department of Veterans Affairs will work with the Department of Defense to create a single point of authority over the Cerner EHR modernization project, VA Secretary Robert Wilkie testified at the Senate “State of the VA” hearing on Wednesday.

HERE’S THE IMPACT

Although the Interagency Program Office was designed to govern the previous VA-DoD EHR project, Wilkie said he understood the agency lacked the governance power. His response mirrored concerns shared with Congress in mid-September that revealed leadership couldn’t agree upon who was in charge of governing the new EHR.

During that hearing, the Government Accountability Office Director of Management Issues Carol Harris testified that both DoD and VA officials have ignored GAO’s advice for years on how to empower the Interagency Program Office. And that, without change, “we are going to continue to have dysfunction in moving forward.”

THE BIGGER TREND

Wilkie stressed that the VA’s Office of Electronic Health Record Modernization and DoD will be “joined at the hip” throughout the project and supported VA OEHRM Director John Windom’s leadership as point-person between the VA and DoD.

“Engaging front-line staff and clinicians is a fundamental aspect in ensuring we meet the program’s goals, and we have begun work with the leadership teams in place in the Pacific Northwest,” Wilkie said.

“OEHRM has established clinical councils from the field that will develop national workflows and serve as change agents at the local level,” he continued. “The work at the IOC sites will help VA identify efficiencies to optimize the schedule, hone governance, refine configurations and standardize processes for future locations.”

In fact, Wilkie said they’ve selected the Veterans Integrated Service Network 20 in the Pacific Northwest as the initial operating capability pilot site that will test the new Cerner EHR. The rollout will follow the DoD’s own EHR rollout in the Pacific Northwest, scheduled to restart implementation on Oct 1.

The partnership with DoD will help VA “understand the challenges and obstacles they are encountering, adapt our approach to mitigate those issues and identify efficiencies,” Wilkie said.

But the DoD has faced a wide range of performance issues with its EHR rollout. The Initial Operational Test and Evaluation found the platform was “not operationally suitable because of poor system usability, insufficient training and help desk support.”

Both DoD and Cerner have repeatedly stressed those issues were expected and the challenges will only benefit future rollouts. In July, Stacy Cummings, program executive officer for Defense Healthcare Management Systems, said DoD has found “measurable success” in its workflow adoptions.

However, if an amendment to the Senate appropriations bill introduced in August is passed, the GAO will review the DoD EHR project.

Yet Wilkie doubled-down.

“My understanding of what went on, on the DoD side, is that they were testing it for mistakes and they found them,” Wilkie said. “I would rather find them there than down the line after we spent the $16 billion.”

The first Cerner install for VA is scheduled to go live in 2020.

Twitter: @JF_Davis_
Email the writer: jessica.davis@himssmedia.com

Athenahealth has received multiple bids, according to CNBC. The prices, reportedly at $131 are below a previous cash bid for the healthcare software firm in an unsolicited move by Paul Singer’s Elliott Management.

WHY IT MATTERS

Hospital CIOs and CFOs that are either already subscribing to athenahealth’s cloud-based EHR or practice management services or considering switching to a new cloud vendor need to know where the company stands. Will it be bought by another EHR maker or taken over by activist investors looking to break it up to make a profit? Or another fate altogether? Those questions will remain unanswered until athenahealth is either acquired or the board makes up its mind to remain independent.

THE TREND

CNBC’s report was based on anonymous sources and did not name which companies might be among the multiple bidders. Earlier this month, however, Healthcare IT News reported that activist investor Elliott Management was putting the brakes on its takeover bid, just two weeks after speculation arose that Elliott might be athenahealth’s best suitor with potential acquirer’s Cerner and UnitedHealth not interested.

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 June, CEO Jonathan Bush stepped down following reports of sexual misconduct and domestic abuse.

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com

So far this week we've offered glimpses about how innovation is pursued at a large academic medical center, and how it looks at a mid-sized for-profit hospital. Now it's time to profile a small facility, where distance from big cities only makes the need to innovate and improve that much more critical.

Artesia, New Mexico has a population of nearly 12,000, but it's surrounded on all sides by empty expanses of scrubby desert.

"Any big city is two to four hours away, whether it's Lubbock, Albuquerque or El Paso," said Eric Jimenez, chief information officer of 49-bed Artesia General Hospital.

That hasn't stopped the small hospital from prioritizing innovation in a big way, he said. It's how Artesia, with an IT staff of just 17 people, was able to successfully attest to HIMSS Stage 6, just two years after replacing its entire EHR and PACS systems.

And there's no rest for the weary. "After we met Stage 6, our next goal was to see how can we improve and get the most out of our EHR," said Jimenez.

The small team is engaged throughout the hospital on that optimization mission, he said, "doing SWOT analyses of our different departments and looking for opportunities where we can streamline the process."

Beyond that, Artesia has higher aims: "My goal is to hit Stage 7 by December of 2018," said Jimenez. "We already have our projects lined out to go that way."

EHR optimization and ownership of innovation

Jimenez applauded his small but scrappy IT shop – past winners of our award for Best Hospital IT Departments.

"I put my team through a lot, and I appreciate what they do," he said. "In the past four years we've hit a lot of milestones. And it wasn't because of me, it was the team I had behind me that supported my innovation ideas."
For example, the benefits that can come from seemingly simple EHR optimization projects – or the integration of just the right add-on app or module – can be huge for a small hospital such as Artesia General.

"I'll give you cardio as the perfect example," said Jimenez. "Our EHR didn't have a way to integrate it in there, so we sat down and they had another piece of software called Epiphany that did all that stuff, so we integrated it in there, worked out the bugs, and eventually the workflow went from a couple days, this backlog of manually entering stuff in the system by scanning it, to instantly. Everything was real time. That was a real innovation."

"If you don't have a happy physician because he's frustrated with the EHR that doesn't help the patient overall."

Eric Jimenez, Artesia General Hospital

The OR is another example. "Our anesthesia providers were upset that they couldn't document in real time. We went to our EHR vendor and they said, 'We don't have anything for them.' So we went out to the market and looked for a good piece of software that would mirror that,” he said. “And then we brought the anesthesia providers in and said, 'OK, here are the three vendors that we're looking at, and how could it improve your workflow.' We got them to buy into it."

The strategy for innovation at a small hospital should stay focused around that human touch, said Jimenez.

"You find their pain points, you show them the solution and then have them buy into that solution. You want to make them feel like they're the owner, and then work alongside them to help clear out their pain points.

"We went from a fully-paper anesthesia process to a fully electronic one, where the anesthesia machines are all sending data to their system and they're actually able to do it in real time," he explained. "Before it would take them days. We just look for broken processes and try to provide them a solution – make them an owner of that solution."

Next goals: Stage 7 and interoperability

As Artesia aims for the two goals of attaining Stage 7 and meeting its numbers for the Promoting Interoperability Programs run by the Centers for Medicare and Medicaid Services, Jimenez says the small hospital is reaching out for helping hands wherever it can find them.

"We're engaged with CommonWell Health Alliance, we're engaged with the state HIE, we're reaching out to a lot of other local hospitals around the area, trying to get that engagement together so we can build a community around our patients," he said.

After all, "patient care and physician usability" should be the twin guiding lights for any hospital innovation initiative, regardless of how big or small it may be.

"Our providers are our bread and butter, so we try to build and innovate around them – investing in technology that will improve their throughput," said Jimenez. "We're looking at virtual scribing, for instance. Because if you don't have a happy physician, because he's frustrated with the EHR, that doesn't help the patient overall."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Healthcare is on the verge of open APIs and data, developer programs from leading software vendors, and an even bigger rush of upstarts and entrepreneurs looking to create digital health tools that usher in a new generation of care delivery fit for consumers by focusing on patient experience.

As exciting as that is, however, there are a few things innovators really need to overcome the prevailing sense that the industry must move faster.

Big electronic health record vendors such as Allscripts, athenahealth, Cerner, eClinicalWorks, Epic and most recently Meditech have third-party developer programs, with varying degrees of participation and success. In the meantime, innovators have the opportunity to create apps for other companies platforms as well.

Here, then, are some basic tenets of innovation that app developers need most from big EHR vendors.

A playbook

It seems so straightforward, but a widely-accepted playbook for app developers doesn't really exist relative to healthcare. "Other industries taking a more open approach look at developers as a customer," said Vince Kuraitis, a consultant currently working on a book, Platforming Healthcare: From Hoarding to Sharing. "There's a playbook outside healthcare about how to be developer-friendly. Apple, Google, they have this down."

Fair and transparent pricing

It’s not easy to know ahead of time how much you will end up paying an EHR company for taking part in their developer program. Some vendors initially took 30 percent of top-line revenue for participating in the developer program, which Tina Joros, Allscripts vice president and general manager of the company's Open Business Unit, said started because that's Apple's price for its own app store. But Allscripts has since changed its policy to offer three tiers, with pricing based on options and usage fees as measured by API calls in a live, production environment. Epic App Orchard Integration Lead Isaac Vetter said that its programs overall costs vary based on API complexity, transactions and how much support Epic provides. “Today the developer is typically charged a revenue share and an annual program fee,” Vetter said. “It is a relatively new program, and as such, we continue to evaluate our pricing structure in response to feedback from our user and developer communities.”

Clear terms of service

HIMSS Innovator-in-Residence Adam Culbertson said one key question destined to emerge from the app ecosystem is exactly what the terms EHR vendors offer developers should be, and will be. "Developer programs need to nail down clear terms of service so innovators can get started," Culbertson said. "The technology alone can't build viable businesses."

A single version of FHIR

The Fast Healthcare Interoperability Resources specification is full of promise. But as of now there are various iterations. "We're moving into the FHIR world but everybody's doing it differently," said Nick Hatt, a senior developer at Redox. "Everybody's excited about FHIR but not thinking about long-term implications of having two separate code bases. If athena or Epic has its own version, there can be out of band quirks." Many eyes are on the next incarnation of FHIR, version 4, to see if it will bring the ecosystem closer to a single standard.

Broader support for FHIR

An upstart developer real early in the process might have a handful of potential hospitals in its pipeline. But if one runs Cerner, another Epic and other Allscripts or athenahealth, the quandary is determining which EHR to commit to before singing that first test customer. "That's the big killer for startups," Hatt said. "It would be nice if you could do everything with FHIR at these places but it's just not the case." It's not like Apple vs. Android where developers have to write for both but then that's it, just the two.

Business side processes

Despite those FHIR challenges, technology can often be the easy part. That's true within developer programs, too. "The tech is only part of what it takes to actually connect a solution," said Tina Joros of Allscripts. "Developers might need help on the business side process, such as how to get the app installed at a client site."

A truly open mindset

EHR vendors have to treat developers as equals to really grow their platform – and that can be hard when their competitive posture is akin to their software being the center of the universe. History and the current state of interoperability would suggest that such a syndrome is more common than not, at least as of today. "The Amazon model is the mindset I'd hope the healthcare industry would aspire to, where you don't kick somebody out of your app store because they're a potential competitor," Kuraitis said. "Amazon is imperfect in the way it treats developers but the general concept of accepting a broad range of apps goes a long way."

Brian Murphy, director of research at Chilmark, said all these factors are gospel for developers, and some will in time be speed bumps that ultimately help EHR vendors and hospitals better serve clinicians and patients by more effectively collaborating themselves.

Until all that happens more widely in healthcare, however, startups will be hindered by the chicken-and-egg conundrum, an obstacle for both EHR vendors and startups alike: How can an EHR maker attract customers to third-party apps without having a bunch of developers building them? And, in turn, how can the company inspire innovators to write to its platform when before providing a range customers who will use the app?

Overcoming that challenge is critical. Because creating an ecosystem of outside developers that can bring new capabilities — writing apps that EHR vendors either don't have the time to add or would never even think of — is necessary, not just for the healthcare industry at large, but for the vendors' own good.

Twitter: SullyHIT
Email the writer: tom.sullivan@himssmedia.com

Thanks to 21st Century Cures Act requirements, private-sector innovation from companies such as Apple and many other factors, the U.S. "might be at a turning point when it comes to the adoption and implementation" of HL7's FHIR standard, according to the Office of the National Coordinator for Health IT.

WHY IT MATTERS

Nearly four year after the launch of the HL7's Argonaut Project – which convened Epic, Cerner, Mayo Clinic, Intermountain and others to create a framework to speed development and deployment of Fast Healthcare Interoperability Resources – the specification seems to be reaching critical mass, potentially pointing to huge innovations for interoperability nationwide.

WHAT IS THE IMPACT

In a blog post, ONC's Steven Posnack and Wes Barker, said several signs point to an inflection point for FHIR, with uptake of the useful data exchange standard on the rise.

All the big electronic health vendors – the 10 with the biggest market share, at least – use FHIR Release 2 as their API standard, and other consumer-facing companies have also embraced the spec, pushing its reach and possibilities even further.

That progress comes thanks to several laws and policies from recent years, of course, including the API requirements in the 21st Century Cures Act and ONC's stringent 2015 Edition certification criteria.

The net result, said Posnack and Barker, is that "many companies have gone into production with FHIR Release 2 profiled according to the Argonaut implementation specifications."

Apple's FHIR-based client app has gotten a lot of attention, they noted, and the recent high-profile vote of confidence for HL7's Argonaut from Amazon, Google, IBM, Microsoft, Oracle and Salesforce is only building the momentum – suggesting that "many other big tech companies are also planning to use the standard."

In addition, the Centers for Medicare and Medicaid Services has also amplified FHIR's reach through initiatives such as Blue Button 2.0.

WHAT IS THE TREND

ONC looked closely at its own data, along with data from CMS, to assess how hospitals and physician practices accessed 2015 Edition certified-APIs, and how the trends varied nationwide.

About 32 percent of developers certified to the "application access-data category request" section of the 2015 criteria said are using FHIR Release 2, Posnack and Barker noted – and almost 51 percent of developers seem to be using some version of FHIR combined with OAuth 2.0.

"While the 32 percent may seem low the estimated market share of the health IT developers using FHIR is large," they emphasized – pointing to a table showing Epic, Cerner, Meditech, Allscripts and the rest of the 10 largest EHR makers all using FHIR Release 2 for their 2015 Edition certified health IT.

That technology is used, all told, by 82 percent of hospitals and 64 percent of practices.

"Overall, of the hospitals and Merit-based Incentive Payment System eligible clinicians that use certified products, we find that almost 87 percent of hospitals and 69 percent of MIPS eligible clinicians are served by health IT developers with product(s) certified to any FHIR version," they wrote. "When estimated for just FHIR Release 2, the hospital percentage remains the same while the clinician percentage drops a bit to 57 percent."

ON THE RECORD

There are still some skeptics, however. In a statement responding to ONC's blog post, Premier suggested that the FHIR-favorable headlines made in recent months by Apple, Amazon, Google and the rest are welcome – but there's a lot more left to do.

While developers' coalescence around FHIR for consumer apps was promising, the government should "prioritize achieving a similar degree of development across provider facing applications," for analytics, workflow, decision support and more.

As Blair Childs, Premier's senior vice president of public affairs explained: "A strict focus on consuming facing apps provides a limited view into the state of interoperability. It gives false hope of reaching the tipping point for free and unencumbered data exchange in healthcare. The reality is that we are nowhere near reaching our goal of a data-enabled health system.

"Until all data is unlocked from EHRs and integrated into clinical workflows, we will continue to face walled gardens of vital information," he added.

Indeed, ONC seemed to recognize some of those limitations.

"While these data are encouraging, it’s not time to pop any champagne," said Posnack and Barker. "Industry-wide, much work remains from standards development to implementation."

They reminded FHIR developers that "the standards community needs your help," and encouraged them to add pilot projects to ONC's Interoperability Proving Ground and tag it with "FHIR" to help fuel the agency's research.

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

A total of 77 provider organizations earned Stage 7 of the HIMSS Analytics Electronic Medical Record Adoption Model last month and two others revalidated for Stage 7 as well.

It bears explaining that many of those are health systems with multiple facilities that all earned a stage, according to HIMSS Analytics.

The same applies to EMRAM Stage 6, of course, and 164 providers earned that designation for the first time in September -- while another 24 revalidated.

[HIMSS Analytics now offers a free version of its Logic Analyze News weekly newsletter: Subscribe]

Also of note are hospitals outside the U.S. In China, for instance, Beijing ChuiYangLiu Hospital garnered a Stage 6 and Shengjing Hospital of China Medical University a Stage 7. And in Canada, both Humber River Regional Hospital and the Hospital for Sick Children Outpatient Services achieved Stage 6.   

Here’s the full list:

Cerner shared the list of the 24 health IT vendors that will support the U.S. Department of Veterans Affairs’ transition to from its legacy VistA EHR to the Cerner platform.

THE IMPACT

Accenture, Leidos and AbleVets are among the leading names of vendors that will support the project throughout the projected 10-year timeframe. Many of the vendors are veteran-owned, which will provide insight into the massive undertaking, officials said.

“This is the beginning of a long transformational journey,” Travis Dalton, president of Cerner Government Services, said in a statement. “We’ll continue to seek and bring the best talent available to the VA.”

“Our nation’s Veterans deserve the highest quality care,” he added. “And we’re confident we’ve brought the right players to this team to succeed in our collective mission.”

The complete list of vendors can be found here. Officials said that both the Cerner and VA EHR modernization team will outline the strategy for the project during Cerner’s conference from Oct. 8 to 11.

THE TREND

This is just the latest step forward for what will be the largest EHR undertaking in the country. Officials said the EHR is scheduled to roll out in line with the Department of Defense’s own Cerner EHR rollout. The VA has repeatedly projected their rollout will go live in the Pacific Northwest in 2020.

Just last week, VA and DoD officials said they intend to create a single point of governance for the project, following a hearing where Congress blasted the agencies for not leveraging the Interagency Program Office.

The IPO was established by Congress during the first DoD-VA attempt at a shared EHR platform -- but officials said they lack authority, staff and funding for the undertaking.

During the Sept. 26 hearing, the agencies also announced the first pilot site will be the Veterans Integrated Service Network 20 in the Pacific Northwest. The site will act as the initial operating capability pilot site to test the Cerner project.

Given the number of challenges the Cerner project has faced at the DoD, the agencies are exercising an abundance of caution and working closely with the appropriate parties to ensure the VA’s rollout goes off without a hitch.

Twitter: @JF_Davis_
Email the writer: jessica.davis@himssmedia.com

Children with complex conditions need additional time, medical care and rehabilitative services for recovery after hospital discharge. However, unique challenges persist in finding post-acute beds and the appropriate care.

The 2014 study Pediatric Post-Acute Care Hospital Transitions: An Evaluation of Current Practice, the first known to detail frequent use of admission and discharge practices for U.S. pediatric hospitals, found variability exists in transition practices. As hospitals take a harder look at transitional care strategies to address value-based care coupled with aging adults, children must be considered.

THE PROBLEM

At Children's National Health System in Washington, D.C., case managers placing children with specialized needs often encountered facilities ill-equipped to care for certain conditions and lacking in pediatric nurses, beds or appropriate medical equipment, for example, feeding tubes and adapters.
 
Another challenge was finding local subacute care. Case managers spent extraordinary time addressing these issues in addition to printing and faxing documents – medical history, progress notes, discharge summary and more in the patient's electronic record – to providers. Follow-up calls were placed to ensure receipt and if additional information was needed. Incessant waiting ensued to learn whether the patient was accepted.
 
PROPOSAL

Two years ago the health system decided to reconfigure its post-acute care transitions to achieve seamless patient handoffs. The institution turned to a more strategic use of technology to eliminate time-consuming clerical activities and match the right facility to support the patient's healing journey. Children's National decided on care coordination technology vendor Ensocare.
 
MARKETPLACE

There are many care coordination systems on the market. Besides Ensocare, vendors include Allscripts, b.well, Caremerge, Imprivata, MyHealthDirect, PatientPing, pMD and Seremedi. This past month, Microsoft revealed plans to bring its own care coordination tools to market.
 
MEETING THE CHALLENGE

Ensocare Transition is care coordination software that enables Children's National Health System case managers and discharge planners to connect patients and their families with the appropriate discharge resources fast and efficiently.

The discharge planners use the software for all existing patients who either need specialized resources at home specific to their condition or require placement and transition support to sub-acute care and rehab facilities.
 
"Previously, our case managers placing children with specialized needs often encountered facilities ill-equipped to care for certain conditions and lacking in pediatric nurses, beds or appropriate medical equipment," said Sabrina Smallwood-Mason, RN, nurse lead and payer reimbursement analyst, denials and appeals, at Children's National Health System.

"Another challenge was finding local subacute care," she added. "The case manager spent extraordinary time addressing these issues in addition to printing and faxing documents to providers."
 
In using the care coordination software over the last two years, Children's National is disseminating those same documents bundled in 237 custom referral packets monthly to the right, matched provider. The packets also include the last three days of inpatient stay and the patient's demographics and insurer information. The health system also is introducing Ensocare to its outpatient case managers to help provide new resources to patients and families.
 
Ensocare Transition is embedded within the health system's Cerner electronic health record system.
 
"If the two systems weren't compatible, automated discharge planning and smooth post-acute care transitions simply would not work," Smallwood-Mason explained. "The integration eliminates the need for faxing, repetitious phone calling and other time-consuming clerical activities.

"Once the discharge planner selects and customizes the appropriate referral placement packet for the patient, the employee can then move to the next step of selecting the appropriate clinical and service-related vendors who best fit the clinical and psychosocial needs of the patient," she added.
 
Within seconds, that selected patient-specific packet information is transmitted to the right, matched facility to support the patient's post-care healing journey.
 
RESULTS

As mentioned, using the care coordination hospital discharge system, 23 Children's National case managers today can disseminate key documents bundled in 237 custom referral packets monthly to the right provider.

Response time averages 30 to 40 minutes from 80 percent of contracted skilled nursing, rehab, home health and other eligible providers, who are more responsive helping children transition to post-acute care facilities, Smallwood-Mason said.
 
"Case managers previously completed referrals sent to providers by faxing documents printed from the electronic record,” she added. ”This faxing activity was time-consuming and overwhelming by nature of the sheer volume of pages per patient."
 
In addition, since faxes were not always transmitted securely, case managers placed follow-up phone calls to ensure receipt, she said.
 
"Today, they no longer have to perform both tasks and the upshot is increased productivity," she said. "The system permits the case manager to view the time and date of when the referral is opened, and when the provider has accepted, considered or declined the request. The case manager can communicate via text with any identified matching post-acute care provider as needed."
 
The care coordination software also enhances information accuracy, she said.
 
Children's National also achieved a significant cost savings for the department by eliminating paper purchases, overtime and clerical staff hours, she added.
 
While the same clinical information is captured as with any referral, documents such as charity applications can be obtained for the patient or family member to complete, alongside captured financial documentation.

On another front, it is fair to say that prior to using the care coordination software, completing a referral was not seamless, Smallwood-Mason said. The software allows the case manager to see what is going on with the referral throughout the process, eliminating guesswork, she explained.
 
"Prior to the software, time for referral completion could be variable, from hours to days in some instances," she said. "The need for communication via phone was a must to verify if the referral was received, if all necessary documents necessary for the referral were received, and also when services would be provided. This was an issue, as it required the case manager to be available to receive the phone calls from providers."
 
ADVICE FOR OTHERS

"I would tell anyone struggling with the clerical inefficiencies that are inherent to the 'way we've always done case management' to consider just how much time you can free up by turning to technology solutions," said Smallwood-Mason. "A lot of case managers believe that the technology will 'take their jobs' or replace them."
 
In fact, letting technology handle those things that can be automated gives the case manager more time to spend face to face with patients, she said. It's the reason most joined this profession, to help people – standing at a fax machine eight hours a day isn't helping people.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

With a proverbial flip of the switch at three locations in Florida and Arizona, Mayo Clinic has completed its $1.5 billion Epic electronic health record implementation, linking all Mayo sites on an integrated EHR and revenue cycle management system.

WHY IT MATTERS
The Mayo Clinic rollout, called the Plummer Project, in honor of Henry Plummer, MD, who developed a patient-centered health record at Mayo in 1907, is one of the largest, most complex and most expensive Epic implementations ever.

First announced in early 2015, the initiative, which sought to replace the health system's existing Cerner and GE systems, had been under consideration for years, said Mayo Clinic CIO Cris Ross. "We really believe that an integrated EHR, across all of our organizations, can help us with that core mission of meeting patients' needs," he told Healthcare IT News at the time.

Ross predicted then that rollout would take "about four years to complete." Given that the first two-dozen sites went live in Juy 2017, it's coming in ahead of schedule.

There were several milestones along the way, notably go-lives at Mayo Clinic Health System in in November 2017 and Mayo Clinic in Rochester this past May. All told, the project depended on the expertise of nearly 500 IT staff. Now, some 52,000 Mayo employees are using Epic across 90 hospitals and clinics in the Minnesota, Florida and Arizona.

"The project is highly complex due to the number of specialties and subspecialties involved," said Ross in another interview earlier this year. "We are not only focused on building and delivering a converged technical solution. We are also invested in the people side of change to support them in adopting, utilizing, and becoming proficient in the Epic system. This is being accomplished through a comprehensive change management strategy."

WHAT IS THE TREND
Mayo Clinic says the complexity and expense of the project were worthwhile investment for a single unified system that connects patients and providers across the health system, enabling easier access to clinical and billing information regardless of location.

More and more, large U.S. health systems such as Mayo are gravitating toward either Epic and Cerner, and the same trend is now also playing out overseas.

Other major Epic deals this year include Chicago-based Advocate Health Care and Trinity Health in Michigan.

ON THE RECORD
"Having one integrated system builds on our core mission of putting the needs of patients first,” says Steve Peters, MD, co-chair of the Plummer Project, in a statement. "This will enable us to enhance services, accelerate innovation and provide better care."

"The commitment and expertise of outstanding Mayo staff, Epic colleagues and implementation partners brought us to this day," added co-chair Richard Gray, MD. "We envision even greater collaboration among experts in delivering the patient care, research and education that are hallmarks of Mayo."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Seventy-four percent of healthcare provider organizations use clinical decision support technology, according to a new study from Reaction Data relying on CDS to make more informed medication orders (30 percent), lab orders (24 percent), medical imaging orders (20 percent), choosing wisely (13 percent) and other (13 percent).

The report polled interviewed 180 clinical, quality and IT healthcare leaders at in providers nationwide (91 percent were acute care facilities and 9 percent were ambulatory) to assess the state of clinical decision support technology in the U.S. healthcare industry today.

WHY IT MATTERS
Clinical decision support systems are used to help providers make better, safer and quicker decisions at the point of care.

But for all their value, decision support tools "do not come without their own list of struggles," according to the report. "Many companies will employ a standalone CDS solution, and while they are great at what they do, can be hard to integrate with the provider's EHR.

"On the flipside, some may opt for a more basic solution that integrates well with their EHR, but miss out on some of the robust functionality you get from a specific standalone system."

The Reaction Data study particularly matters because it defines the vendor marketplace for clinical decision support systems as used by healthcare provider organizations today.

The top 11 clinical decision support tech vendors in use today are: Cerner (25 percent), EPSi/Allscripts (14 percent), Epic (11 percent), Stanson Health (6 percent), Nuance (5 percent), Premier (5 percent), Truven/IBM (4 percent), Elsevier (4 percent), Zynx Health (3 percent), NDSC/Change (2 percent) and CPSI/Evident (2 percent).

WHAT IS THE TREND
More than half (55 percent) of healthcare provider organizations use multiple clinical decision support systems, the Reaction Data study found. When it comes to future plans, 48 percent of organizations plan to keep multiple systems, 26 percent plan to standardize on one platform, and 26 percent are unsure.

At Saint Luke's Health System in Kansas City, Missouri, where transfer patients from various rural and community-based hospitals throughout the area are accepted, the provider noticed increased mortality from sepsis among such patients due to this time-sensitive and deadly condition not being diagnosed early enough.

Saint Luke's worked with vendor Redivus Health to implement a sepsis screening program that operated outside the EHR to proactively address this problem. The nurse transfer team began using the Redivus clinical decision support platform in 2017. The goals of the pilot program were to identify sepsis patients at the transferring facilities, start treatment sooner and improve patient outcomes.

The clinical decision support platform enabled transfer nurses to identify significantly more (200-plus) sepsis cases by providing simple intuitive guidance, and it allowed for patients to receive time-critical treatment before being transported to a higher level of care.

Results of the six-month pilot program were stark. The clinical decision support platform helped identify 150 percent more sepsis patients; it decreased mortality by 30 percent, which led to approximately 20 lives saved; and it correctly identified and treated sepsis, increasing billing income by $70,000 per month.

ON THE RECORD
"Surprisingly, almost half of those (providers) using multiple solutions still see themselves doing so in the future," accorind to the Reaction Data report, Clinical Decision Support 2018. "This either means there's a market for best-of-bread type solutions, or for a newcomer to create a product that providers feel meet all of their CDS needs."

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

As the opioid crisis continues to spread nationwide, it's requiring an all-hands-on-deck effort to turn the tide. Health information technology – electronic health record customizations, predictive analytics algorithms, e-prescribing tools – is proving to be a valuable weapon in the fight.

As part of National Health IT Week, a HIMSS Media webinar on Tuesday detailed the efforts of two HIMSS Davies Award-winning providers, Ochsner Health System and Bon Secours Mercy Health to leverage technology to stem opioid addiction in their patients.

While both are large health systems, the lessons they've learned in putting data science and EHR optimization to work point to some strategies and best practices for other hospitals facing the same battle: the largest drug epidemic in U.S. history, with opioid overdoses having more than quadrupled over the past 20 years.

"We're in the midst of the most challenging public health concern facing healthcare professionals and first responders today," said Jedediah Tuten, director of acute pharmacy operations at Bon Secours Mercy Health.

Opioid risk tools, MEDD calculators enhance the EHR

Ohio, where 19 of Mercy's 21 hospitals are based, has been one of the states most affected by the opioid epidemic. (So is Kentucky, where its other two hospitals are located.) It's a huge challenge in Louisiana, too, where Ochsner Health is based.

Todd Burstain, MD, Ochsner's chief medical informatics officer, explained on the webinar how the health system has implemented tweaks to its EHR to show prescription data to ED physicians – effecting a big reduction in opioid prescription.

It also turned to analytics for several different insights about how prescription patterns, when opioids were called for, could work better. For instance, there was concern among many that fewer pain meds would result in an adverse patient experience – and lower HCAHPS scores.

"We we went to the analytics and found no relation between prescribing rates for Opioids and patient satisfaction," said Burstain. "That was key initially to gain the confidence of some of the naysayers and alleviate those fears."

Ochsner also customized its Epic system with an opioid risk tool and a morphine equivalent daily dose, or MEDD, calculator to help clinicians better understand the potency of the drugs they're prescribing and their patients' potential for abusing them.

Whether in the ED or with discharge order sets, "we wanted to identify patients who did need opioid therapy and what the risk was, and how we could better monitor them," he said. The risk tool questionnaire, without disrupting workflow, helped offer "sensitivity and specificity about who was at risk."

Clinical buy-in, IT leadership are must-haves

At Bon Secours Mercy Health, Tuten explained, the hospitals are constantly honing their opioid strategy as national guidelines and state regulations change, not least when it comes to building new tools into its EHR.

Clinical buy-in and engagement is key to the success of those adjusted processes, he said – and so is IT leadership, which is "integral to providing access to controlled substance data at the right time in clinical workflows with minimal effort from staff," and the training for the new workflows and tools that become available.

Attention to details that other providers might overlook has served the Mercy Health well, he said – for example the issue of free-text sigs in eRx. Tuten pointed out that about 10 percent of all opioid prescription were written with non-discrete elements of dose, route or frequency, hindering the health system's ability to auto-calculate MEDD or tracked it over time.

Mercy Health now requires discrete sigs, with free-text not allowed as of this past month. It required board approval and intensive provider education, but the opportunity for improved visibility into prescribing patterns and better analytics data in general has made the effort worthwhile.

Mercy Health's opioid analytics platform enables tracking of prescribing behavior at the "order, provider, department, specialty, market, and enterprise levels," as HIMSS points out in its Davies Award case study.

That's one reason the health system has been able to improve its opioid dispensing practices across the enterprise, enabling a 13 percent reduction in total opioid orders; a 22 percent reduction in the rate of opioid orders to all medication orders; a 35 percent reduction in the rate of MEDD > 30 to acute opioid orders; a 14 percent reduction in the rate of MEDD > 80 to opioid orders; and a 23 percent reduction in total morphine equivalents prescribed per patient.

Toward similar goals, other hospitals and health systems should take Tuten's advice on joining the tech-enabled fight against opioids.

"Buy-in, engagement and education is imperative from the top down, across the multidisciplinary teams in the organization," he said. "Identify a champion, tell your story, use the tools and data available to you, use feedback from frontline staff on the efficacy and efficiency of protocols developed and include them in policy design and implementation. And take full advantage of the efficiency provided by your information technology."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Penn Medicine is pursuing a new initiative it says will innovate electronic health records for 21st Century medicine. The goal, officials say, is to make the technology more interactive and responsive to clinicians – nudging the EHR into a new era where it's not just a documentation system but a crucial tool for care delivery.

WHY IT MATTERS

Since EHRs have become ubiquitous over the past decade, they've grown into an intrinsic part of the ways healthcare is administered. They've also earned no shortage of annoyance, if not downright scorn, from many clinicians frustrated by how they impact their jobs.

As Penn Medicine explains, many physicians simply see EHRs as "static, digital remakes of paper charts that can increase workload, contribute to burnout and create barriers to delivering high-quality patient care."

And oftentimes that's exactly what they are. But as is often the case, much depends on how such tools are used. So Penn Medicine leadership has undertaken a multi-pronged approach to making EHRs more responsive to clinicians and streamlining them to work better for better outcomes in the era of precision medicine and population health management.

The Penn Medicine Nudge Unit – billed as the first behavioral design team developed at a health system – is key to the mapping of these new approaches to the EHR experience.

For instance, it has devised new tweaks for Penn's Epic system designed to help ensure clinicians prescribe statins for their cholesterol patients, get cardiac patients referred for rehab after heart attacks and only order advanced imaging tests for the patients who need them most.

David Asch, MD, executive director of the Penn Medicine Center for Health Care Innovation, has previously explained how behavioral economics and psychology are key to engaging patients to make meaningful changes.

The same holds true for physicians, he says, which is why he's advocated for EHR customizations that, among other things, enable and encourage doctors to "subscribe" to their patients' clinical data, gaining social media-like updates in real time when certain interventions are needed.

"Ultimately, we need to move past the idea that the EHR is just an administrative tool, and see it as a clinical tool – like a scalpel, or a medication, or an X-ray machine," Asch said in a statement announcing the new project. "We judge these tools by the degree to which they facilitate good patient care, and we should be judging the EHR against the very same standard."

THE BIGGER TREND

Much has been said, here and elsewhere, about the "post-EHR era," but Penn Medicine's efforts appear to be intent on making it a reality there – boosting the ability of IT systems to deliver enhanced care in the 21st Century.

No longer just a data repository or a glorified billing system, the EHR – when properly designed, configured and used – could have a huge impact on how care is delivered, especially as the complex new era of connected devices, patient-generated health data, genomic medicine and artificial intelligence continues to come into focus.

A chief goal at Penn Medicine, officials said, is to alleviate if not eliminate the need for clinicians to spend undue time looking for needles in data haystacks, getting pertinent patient information in a more "actionable, tailored manner."

That's why the health system has also launched a new innovation contest designed to get teams from across Penn Medicine to identify the lowest-hanging fruit for EHR transformation. IT professionals, data scientists, educators and others will work with clinicians and staff to help conceive and refine various design and usability improvements.

In addition, new so-called "sprints" – collaborative clinical workgroups to help to streamline and improve EHR interactions and engagement with email and  digital media – will be a key component of the new initiative going forward.

ON THE RECORD

"We recognize that EHRs are no longer just part of how clinical care is documented, but they are central to how clinical care is delivered," said J. Larry Jameson, MD, dean of Penn's Perelman School of Medicine, in a statement. "Increasingly, health information technology plays a foundational role in each domain of our work: patient care, educating the next generation of physicians and scientists, and biomedical research."

Ralph Muller, CEO of the University of Pennsylvania Health System added: "Everything that shapes patient care should be designed to support the best possible outcomes. Electronic health records are a natural focus because they connect to everything we do."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

The IT journey in clinical systems in Singapore dates back to the 1980s and by the early 2000s, two distinct electronic medical record (EMR) systems emerged from the two integrated clusters. However, this meant that sharing of patient information, especially those moving from different clusters, was a big challenge.

In 2008, the National Electronic Healthcare Record (NEHR) was conceived out of a “one patient, one record” vision based on a concept paper. Critically, NEHR differs from previous EMR systems as it is a repository of visit summaries specific to an individual. While EMR systems contain detailed information of a patient in their respective institutions, NEHR collects key subsets of health information from these multiple healthcare encounters.

NEHR went live in 2011, with the successful uploading of healthcare information from public hospitals in the same year. By the first year, all restructured hospitals, specialist centres and polyclinics, six community hospitals, eight nursing homes, and an increase from an initial 50 to 250 GP clinics had access to NEHR.

HealthHub, a one-stop portal and mobile application for Singaporeans to access a wide range of health content, rewards and e-services was launched in 2015. Users can also log-in to HealthHub through their SingPass to view their health records and medical appointments across different polyclinics, public hospitals and other public health institutions. The information from HealthHub is drawn from a few IT systems, which include the NEHR, the School Health System, School Dental System and National Immunisation Registry.

As of November 2017, only three percent of the more than 4,000 private healthcare providers – including specialist clinics, nursing homes and hospices – contribute to the NEHR scheme. Additionally, a study of private healthcare institutions done by the Integrated Health Information Systems (IHiS), the national technology agency for healthcare, found that two in 10 private GPs and specialist clinics still use written medical record systems, rather than an electronic one. At the time of writing, the Ministry of Health (MOH) website has a list of 1230 healthcare institutions/organisations (public and private) who are participating in NEHR.

Due to the slow uptake by private healthcare sector in the NEHR, MOH wants to make it compulsory for all healthcare providers to upload data to the NEHR. Early adopters who start contributing data by June 2019 will be able to claim a one-off from MOH to offset their costs of upgrading their systems and a S$20 million fund has been set aside by the ministry for this purpose.

One of the unique developments is that the latest generation of the Singapore Armed Forces (SAF)’s EMR system, Patient Care Enhancement System (PACES) 3, which was launched in April 2016, connects to healthcare infrastructure outside of Ministry of Defence (MINDEF)/SAF via the internet, such as the NEHR. This helps to provide more holistic care for SAF servicemen. Traditionally, the first two generations of PACES operated independently on their own with no ability to connect to external healthcare infrastructures.

While there has been a progressive development in health IT in Singapore in terms of the NEHR and HealthHub, the nation-state suffered a setback in its goal to becoming a Smart Nation when a cyberattack occurred to SingHealth, Singapore’s largest group of healthcare institutions, which consists of 4 public hospitals island wide, 5 national specialty centres and a network of 9 polyclinics in July 2018. Described as one of the worst cyberattacks in the country, the incident saw the personal information of 1.5 million SingHealth patients being copied and stolen.

Plans for compulsory contribution to NEHR has been suspended temporarily after the SingHealth incident and a four-member Committee of Inquiry (COI) was set up promptly to look into the events and factors that led to the attack. In response to the incident, Prime Minister Lee Hsien Loong shared, “If we discover a breach, we must promptly put it right, improve our systems, and inform the people affected. This is what we are doing in this case. We cannot go back to paper records and files. We have to go forward, to build a secure and smart nation.”

PM Lee’s response reflects Singapore’s ongoing journey in continually advancing healthcare IT infrastructure – in fact, there are already plans to develop and implement the Next Generation Electronic Medical Record (NGEMR) by 2020.

Change Healthcare has announced that CarePort Health, a leader in discharge planning and utilization review, has become the first provider partner to fully integrate the Change Healthcare InterQual Connect and InterQual AutoReview products into its Care Management application and into the workflow of its users.

With this functionality, CarePort customers can now receive automated medical reviews sent straight to their Care Management workflow, thereby reducing administrative burden and allowing more time for managing patient care, the companies said.

WHY IT MATTERS

CarePort was acquired by Allscripts in 2016. InterQual AutoReview is a SaaS, Robotic Process Automation application that automates the InterQual medical review by extracting clinical data directly from leading electronic health records. The completed review is then transmitted directly to InterQual Connect’s Medical Review Service, integrated within the CarePort Care Management system.

The result is that users of CarePort Care Management gain automated, evidence-based clinical decision support within their workflow, helping ensure that patients receive the most appropriate care while freeing clinicians from the burden of manual medical reviews.

Along with enabling InterQual AutoReview, InterQual Connect Medical Review Service provides CarePort customers with a new InterQual user interface, plus additional value by ensuring that they have access to the most current clinical criteria -- available as soon as they are published to the cloud -- as well as custom policies published by connected payers.

THE BIGGER TREND

Tech vendors and, in some cases health systems themselves, are working to deliver clinicians better tools for decision making and reduce administrative burden. From Penn Medicine re-tuning its EHR with its Penn Medicine Nudge Unit to Tampa General tapping analytics for clinical best practices, as the broader healthcare market is accelerating beyond the EHR, according to a new HIMSS Analytics state of the HIT industry report. 

THEIR TAKE

Lissy Hu, CarePort CEO and founder added: “With this integration, CarePort customers are now able to create automated medical reviews and add them to their Care Management workflow, reducing administrative burden and increasing quality patient care.”

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com

The Sequoia Project is opening up a new front on its push to solve interoperability. As a public-private collaboration comprising experts from disparate spheres of healthcare and technology, the new group, Interoperability Matters, aims to draw on their expertise to find new approaches to data sharing.

WHY IT MATTERS
Interoperability is a large and complex challenge, with many different stakeholders with often competing imperatives and priorities. There are lots of reasons why it continues to be an elusive goal for healthcare.

The goal of Interoperability Matters is to bring together experts to identify discrete and specific hurdles to easier and more widespread data exchange nationwide, then prioritize them and working together to solve them.

According to The Sequoia Project, which invites interested parties from across healthcare to participate:

• Workgroups are formed of subject matter experts and critical stakeholders from across industry and government for each prioritized issue.
• Each workgroup informs the Advisory Group with regular, virtual updates to solicit broad consensus on developing recommendations.
• Recommendations of the workgroup are then shared with the public to seek input from those impacted by the work.
• The final work product is a consensus-built resource and plan of action for the healthcare sector to leverage and implement to minimize or eliminate that particular barrier to exchange.

By gathering experts in technology, policy, business and beyond, the group aims to untangle those specific challenges one by one – starting with information blocking.

WHAT IS THE TREND
Information blocking, defined by the Office of the National Coordinator for Health IT as an instance when a provider or EHR vendor "knowingly and unreasonably interferes with the exchange and use of electronic health information," is a fundamental challenge to start with.

While some have expressed skepticism about just how widespread the practice really is, where it does occur there are potentially big patient safety risks. ONC has promised audits and potential fines for those caught doing it, and even some vendors have called on HHS to do more to fight it.

Interoperability Matters will first home in on information blocking, in advance of ONC's expected proposed rule on the matter, said Sequoia officials. It is then expected to tackle other specific angles related to data exchange challenges

ON THE RECORD
"The pipes to enable health information exchange have been laid by organizations like Carequality, CommonWell, DirectTrust, eHealth Exchange and health information exchange organizations," explained Mariann Yeager, CEO of The Sequoia Project. "However, there are remaining real and perceived barriers to making exchange more effective and seamless – but not for long.

"Distinguishing legitimate policy differences from information blocking requires deep understanding of complex policy, technical and business issues," she added. "Our Interoperability Matters cooperative will focus on the practical implications of information sharing practices, and it will inform information blocking public policy."