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    A new report from KLAS surveyed more than 100 various-sized providers for insights about how they're relying on technology to help them manage the opioid crisis in their communities. Electronic health records are a basic but critical tool in the fight, and expectations on vendors are high, the study shows.

    WHY IT MATTERS
    The opioid epidemic is affecting every state, but Rather than ranking IT vendors based on the assessments of healthcare decision-makers, as it usually does, KLAS says it was more interested in learning about the strategies provider organizations nationwide are putting to work to improve their opioid stewardship.

    Having become a valuable if not indispensable technology for quality care delivery, EHRs are a go-to first choice for health systems seeking ways to manage the appropriate dispensation of these drugs, according to the report.

    As they seek to keep their patients and populations safe, these providers are leaning on their vendors to help manage opioid stewardship in a variety of ways. Some leading health systems are customizing their IT systems to help them manage the crisis.

    More generally, they're looking for EHRs that link directly to state prescription drug monitoring programs and offer opioid-specific decision support and toolsets that work within clinical workflows, KLAS shows – noting that those organizations across the U.S. that have managed PDMP integration have seen improved ability to spot at-risk patients.

    WHAT IS THE TREND
    Still, more than 90 percent of the organizations in the KLAS report are relying on non-integrated, best-of-breed tools – even if some of the more advanced of these are pushing their primary EHR vendor to bring the new enhancements needed to prevent risky opioid prescriptions and treat misuse. For those who don't have those functionalities yet, most have "high expectations" their vendors will "deliver within the next year."

    Wherever they are with their technology set-up, hospitals and practices are expecting their EHR vendors to "step up and partner with them to help solve the opioid crisis," according to KLAS, which notes that the EHR's centrality within any organization's IT instructure makes it a the ideal tool to help physicians manage opioid stewardship within their usual workflows.

    MARKETPLACE
    The report finds that providers newer to opioid response initiatives will often look toward best-of-breed vendors such as Appriss Health, Surescripts and DrFirst. Appriss Health’s tech is part of of most states' PDMPs, KLAS points out, and it's the third-party vendor most providers said they used for identifying addiction at the point of care and monitoring for risky prescribing habits.

    But when it comes to monitoring for possible drug diversion, health systems often say their existing pharmacy-specific vendors, such as Omnicell, BD and Medacist, are better positioned than their EHR vendors. "Care management for those already addicted is an area ripe for disruption by vendors who can provide good technology for directing care management efforts," researchers said.

    Indeed, "relatively few opioid-specific solutions are currently adopted and live," the report notes. "Epic and Cerner are among the most-often-mentioned vendors who are currently in use, and their customers’ expectations for integrated solutions that help identify, monitor, and prevent opioid misuse throughout a health system have been met with varied levels of fulfilment."

    Elsewhere, KLAS shows that "multiple organizations have been successful using Appriss Health’s Narx Scores to identify potentially at-risk patients. Several Surescripts customers feel the vendor is well positioned to do more but hasn’t stepped up to the challenge. BD and Omnicell are mentioned often for their drug-diversion monitoring capabilities and the insights customers have gained using their solutions."

    ON THE RECORD
    While the EHR is essentially a transactional technology that's akin to a basic utility these days, providers reliance on it is in keeping with the fact that two-thirds of the organizations polled by KLAS call themselves "novices" or "beginners" in opioid stewardship, the report says.

    Only seven providers of the 100-plus surveyed say they're "advanced," meaning they have multiple strategies and technologies in place to directly combat opioid misuse. Still, that's the level health systems will need to strive for to properly fight this epidemic, researchers said.

    "Advanced organizations report that a multifaceted approach – consisting of internal rules, technology partners, alternative treatment options, EPCS and proper legislation – is necessary for effective opioid stewardship," according to the report. "Organizations that take such an approach have realized gains in their fight against opioid misuse."

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

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    Spanning a long and varied three decade career in military medicine with the Royal Australian Air Force (RAAF) and Australian Defence Force (ADF), Air Vice-Marshal (AVM) Tracy Smart demonstrated her versatility and capabilities in both local and overseas appointments in places such as the United States, Timor Leste and the Middle East. Ahead of the HIMSS Asia Pacific conference in November, AVM Smart talks about her role as Surgeon General ADF and Commander Joint Health, the ongoing digital health developments at the organisation and some of the most rewarding moments in her distinguished military career.

    Could you share with us briefly about your role as Commander Joint Health and Surgeon General ADF?

    Essentially, my Surgeon General ADF and Commander Joint Health roles are quite distinct, with different responsibilities.

    As the Commander Joint Health, I am responsible for health support to the Australian Defence Force in the National Support environment to ensure the health preparedness of our members. This means that all military members not deployed on operations are receiving their health support health centres around the country under my command, and are accessing specialist civilian services through our ADF Health Services Contract. It’s my aim to ensure that our people are fit to deploy and that those who become wounded, ill or injured receive timely, high quality health care, when required.

    As Surgeon General ADF I am the senior doctor, and the authoritative source of strategic health advice to Defence and the Government. I also exercise technical authority across all Defence health services, where ever they are delivered. This includes those health services delivered by our single Services - Navy, Army and Air Force – in the operational space.

    Some of the key functions that are executed through Joint Health Command headquarters in Canberra in support of both these roles are:

    •             The provision of health advice to Commanders at all levels

    •             Developing health policy and programs

    •             Delivery of health services to the ADF through a network of facilities in Australia and overseas

    •             Coordination of the joint health capability domain

    •             Coordination of health research

    •             Capability coordination of health material

    The roll out of ADF’s own e-Health information system throughout Australia was completed in December 2014. Could you give us some key updates/developments on the e-Health information system since its launch almost 4 years ago?

    Defence electronic Health System (DeHS) is the first and only nation-wide digitally connected primary healthcare system in Australia. Since its roll out in December 2014, there have been significant improvements in patient episode data entry and reporting to enable the comprehensive health care system delivered by the ADF within Australia, on exercises and on operations.

    We have seen major improvements in patient care, due to the availability of a holistic eHealth record that is accessible by all clinical craft groups, when they need it, regardless of geographic location. Patient privacy and confidentiality have also improved due to role based access.

    Clinical governance has been improved due to the implementation of patient recall and follow-up workflows and system diary entries. Additionally, we now have superior health intelligence and reporting, supporting both clinical decision making and health administration as well as driving workplace efficiencies and rates of effort.

    Over the past 12-18 months, DeHS functionality has enabled Joint Health Command to pursue a number of initiatives such as enhanced mental health screening via the Patient Portal, and inter-agency information sharing agreements with Department of Veterans’ Affairs and the Commonwealth Superannuation Corporation to enable prompt processing of member claims for compensation and entitlements when they are transitioning from service.

    As well as being implemented across our Australian-based health centres, DeHS is now in use on overseas deployments at some of our fixed based locations.

    What do you think are the key challenges and opportunities in the Digital Health Strategy of the ADF?

    Digital health systems will enhance the ADF’s capability through a prevention focused, and rehabilitation oriented approach to Defence health care.

    As with the implementation of any major strategy, the ADF Digital Health Strategy will present some challenges along the way. Some of the challenges include financial constraints on health care delivery and adoption of technologies, and the rising demand for health care services within the ADF and in the Australian community.

    Despite the challenges, I see some fantastic opportunities in the ADF Digital Health Strategy including enabling patients and providers to make informed treatment decisions, whilst also improving clinical outcomes, health business efficiencies, and human performance through disease prevention and injury rehabilitation.

    Overall, these opportunities contribute directly to ADF capability through health readiness, and ensure members are receiving care that is command responsive and member centric.

    How is the ADF working with the Australian Digital Health Agency with regards to the recently launched National Digital Health Strategy & Framework for Action?

    Defence has been working very closely with the Australian Digital Health Agency for many years, and particularly as we plan for the implementation of our future system.

    Our recently developed ADF Digital Health Strategy complements the National agenda led by the Australian Digital Health Agency and is consistent with both the Agency’s Strategy and Framework. It also builds upon Joint Health Command’s existing leadership in digital healthcare, recognising the Defence electronic Health System (DeHS) as the first and only nation-wide digitally connected primary healthcare system.

    The Strategy has been developed in alignment with the My Health Record initiative and will assist in the development of digital health systems that enable improved and more transparent access to and personal control of Defence health information and records. It will inform our future system to ensure that it provides secure, instant access to a patient’s information – whether it is within our health care centres, on board our ships and aircraft, or on exercises and deployments. For our health care providers, digital health systems will provide the necessary technology to reduce their administrative burden so that they can spend more time with patients.

    You have a vast experience and long service record both within the ADF and also in international peacekeeping duties such as in Timor Leste. What would you say are the most rewarding experiences in your distinguished career with the military?

    I have had many rewarding experiences during my career. It is an honour and a privilege to serve my country and I reflect on this every day when I put on my uniform. It is particularly satisfying to be in the top job and drive strategic and cultural change across our health system and the broader ADF.

    A particular highlight for me was serving as part of the United Nations Assistance Mission in Rwanda. My role was Officer Commanding Clinical Services and Aeromedical Evacuation Operations Officer, and as a Squadron Leader I was also the senior RAAF Officer in what was primarily an Army mission. Although our main job was to provide health care to the UN troops, most of our work was humanitarian – caring for the local population. This included people who we rescued from around the country by aeromedical evacuation or by road, and those we chose to treat who had presented to the Kigali General Hospital but who were too sick to be managed there.

    This was an incredibly difficult deployment. We saw many clinical problems that were beyond our previous experience – from the effects of war, such as machete wounds, grenade and mine injuries, to all number of tropical diseases. We also saw lots of kids, many of them orphaned and suffering from malnutrition and diseases, and some of whom died on our watch. We sometimes had to “play God” – allowing people including children to die due to our limited capacity, many of whom would have lived in a first world country. This was very hard on our people, particularly those with kids back home.

    The toll this mission has taken has been extreme. A 2014 Department of Veterans’ Affairs study found that over 32% of those who served now had an accepted claim for a mental health condition. However, there were many positive aspects and it was an incredibly rich experience for me. A personal highlight was caring for the children of Rwanda, including those from the Mother Teresa orphanage in Kigali. As I saw it, each child we saved or left a positive imprint upon had the potential to grow up and make a positive difference in their country, and so represented a small victory. I feel very proud of the work myself and others did over there, how we contributed to stabilising what has become a successful nation, and of how courageous our people were.

    I don't think I'd be where I am now, Surgeon General ADF and Commander Joint Health, without my experience in Rwanda. I may not even still be in the ADF. I learned a lot about myself, about leadership, and about resilience, embracing the view that “whatever doesn't kill you makes you stronger”. In other words, while some tragically have developed PTSD, I believe that I have experienced “post traumatic growth”. It has given me confidence that I can challenge myself in extreme situations and survive.

    Air Vice-Marshal Tracy Smart is a speaker at the inaugural International Military Health IT (IMHIT) track on Day 2 of HIMSS AsiaPac 18 in Brisbane this November.

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    The use of Electronic Patient Records (EPRs) is now an accepted part of modern medicine, as many now recognise that using EPRs is safer and more productive than using paper.

    EPRs or Electronic Medical Records (EMRs), as they are known outside of the UK, are frequently associated with improved simultaneous access, improved legibility, and, most importantly, improved patient safety, especially in areas such as clinical decision support, prescribing and computerised order entry - using the EPR to request blood tests, imaging examinations, and therapy assessments.

    EPRs come in all shapes and sizes and range from the wall-to-wall "one size fits all" monolith approach, to the best of breed/ best of suite to the "home brew" in-house development approach, particularly popular in Spain.

    The approach is often defined by the hospital’s historical investment, the availability of resources - now and in the future, the views and preferences of clinicians, and the ability of the CIO to influence the chief executive and the members of the senior management team. One would hope that whatever the approach looks like, it has come, as a result, of detailed analyses which has thoroughly examined all the pros/ cons and benefits to both clinician and patient.

    Data collected by HIMSS Analytics from over 800 European hospitals (excluding Turkey) tell us that 22 per cent of EPRs are provided as wall to wall "one size fits all" (80 per cent or more applications from the same vendor), 23 per cent of EPR systems are best of breed (less than 50 per cent of applications from the same vendor), 42 per cent are best of suite (when 50 to 79 per cent of applications are from the same vendor), and 13 per cent of EPR systems are in-house developments (50 per cent or more of applications are self-developed).

    Whilst choice of system and the degree of variability in approach is interesting, even unusual, given that most acute care hospitals are all providing healthcare in very much the same way, EPRs all have one thing in common - they all contain structured data fields that "do things". 

    Hospitals invest in IT but see no additional value or benefit from a patient safety or quality of clinical care perspective

    The clue is in the "E", the "E" being an abbreviation for Electronic. If the EPR system collects the height and weight of the patient the system should be able to calculate the patient’s Body Mass Index (BMI). If the BMI is collected, the doctor can be assisted by a "weight based dosing" algorithm, which, together with the patients date of birth, may prevent the doctor from prescribing an adult dose of a drug to a child or help the doctor by ensuring that the dose of the drug is in accordance with the patients BMI. If the EPR is capturing laboratory results the doctor can be assisted to prescribe the appropriate dose of an anti-coagulant because the system is able to recognise the latest INR result.

    EPR systems can also assist members of the nursing team to provide nursing tasks that are commensurate and aligned with different levels of risk. For example, should a falls risk assessment determine that the patient is at high risk of falling, the care plan is automatically populated with nursing interventions that are only associated with this level of risk. This goes some way to ensure that care is standardised and reduces the possibility of low risk interventions being offered when the risk of falling is high.

    To be clear, scanned paper, electronic forms, systems that contain large amounts of unstructured data or 100 per cent free text with no alerts, no warnings, and no clinical decision support are not EPR systems. The abbreviated "E" in this case probably stands for Electric.

    Sadly, we see hospitals that have invested significantly in information technology, more systems than sense, multiple clinical data stores, little connectivity, robots in all the right places, but no additional value or benefit from a patient safety or quality of clinical care perspective. 

    So, if you are a Chief Information Officer or a Chief Clinical Information officer reading this, make yourself a note to review all the data fields within your clinical application(s) to make sure that first of all those clinical data fields are capable of receiving structured data and then that those data fields actually do something to help clinicians. If your EPR is helping clinicians with clinical decision support, well calibrated alerts and warnings your EPR is likely to be electronic, if not, it’s an electric record. 

    Finally, if you have persuaded the Chief Executive and members of the Senior Management Team to invest in scanning facilities and an Electronic Document Management system as an alternative to an EPR system, you may be at some point be asked to explain why.

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    Rangely District Hospital in Rangely, Colorado, was struggling to show progress toward quality measures with limited reporting tools. It was at risk of missing out on revenue from Medicaid and Medicare.

    THE PROBLEM

    The hospital was losing valuable physician and staff time making up for missing functionality. It had inefficient and time-consuming processes for securing authorizations. And it was financially burdened with unexpected add-on costs.

    “As a critical access hospital that primarily services Medicaid- and Medicare-eligible patients in rural Colorado, our financial health is strongly linked to performance on quality measures,” said Bernie Rice, chief compliance officer at Rangely District Hospital. “But our former IT services were making it harder, not easier, to report out on our performance, which put our ability to collect full payment in jeopardy.”

    Clinicians and staff also were losing time fixing problems caused by lack of functionality, and EHR vendor Meditech’s business model was adding to the hospital’s financial stress, rather than reducing it, Rice said. Because of missing functionality, caregivers and staff were losing time; for example, payer rules were not automatically updated so staff had to read payer bulletins and manually update billing rules in the systems, he added.

    “Rangely staff also had to manually change how dictionaries were built and update our chargemaster with the correct codes,” he explained. “This made it harder to ensure claims were submitted correctly the first time, report out on performance, or fulfill the large volume of audit requests we received.”

    Further, contacting Meditech’s support teams created more problems as their tech support teams were very hard to work with and didn’t seem to be subject matter experts, Rice said. The hospital also faced additional financial stresses through add-on fees, including fees for updates, he added.

    PROPOSAL

    Rangely District Hospital turned to EHR vendor athenahealth to help with generating necessary reports, cleaning up the claims submission process, and lowering operational costs, with the ultimate aim of meeting state and federal quality requirements.

    MARKETPLACE

    There are a great many EHRs on the market today, each with varying degrees of functionality, including reporting abilities. EHR vendors include Allscripts, Cerner, eClinicalWorks, Epic, Greenway Health, Netsmart and NextGen Healthcare.

    MEETING THE CHALLENGE

    After implementing athenaOne for Hospitals and Health Systems, the hospital generated reports it needed, streamlined its claims submission process, reduced operational costs, all allowing staff to focus on things that mattered most, Rice said.

    “We’ve already made progress toward meeting state and federal quality requirements,” Rice said. “The new services also helped us to efficiently prepare and submit claims, which contributed to a 53 percent increase in baseline cash collections.”

    athenahealth’s Billings Rules Engine tracks changes to over 40 million payer rules and uses that information to identify errors before the hospital submits claims, Rice explained. Days in accounts receivable have gone down 15 percent.

    “We’re eliminating costs and probably saving somewhere around $300,000 to $500,000 a year, and not spending a lot of time thinking about where we’re going to find $100,000 for the next interface,” Rice said.

    The staff doesn’t have to dedicate large amounts of time to manually calling to get prior authorizations, Rice added. Those people, in turn, are a lot happier, he said.

    RESULTS

    In addition to the aforementioned benefits, easier reporting enables staff to respond quickly to audit requests from state, federal and other organizations, Rice said.

    There has been a 53 percent increase in cash collections over baseline since go-live, a 15 percent decrease in days in accounts receivable, assistance from time-saving tools that automatically track changes to payer rules, authorization management services that free up staff to take on high-value work, and reduced operating costs with transparent pricing that includes upgrades and interfaces, Rice detailed.

    ADVICE FOR OTHERS

    “You have to look for more of a partnership opportunity,” Rice said, “rather than a vendor contract.”

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    In 1995, the Singapore Armed Forces (SAF) Medical Corps introduced a large scale Electronic Medical Records (EMR) system, the first of its kind in Singapore. In less than a decade, the improved second generation of the EMR was implemented and most recently, the latest generation of its EMR system was rolled out in April 2016.

    In an interview with Healthcare IT News Asia Pacific, RADM (Dr) Tang Kong Choong, Chief of the SAF Medical Corps, gave an update on the recent developments at the organisation as well as some of the lessons learnt behind the implementation of the third generation EMR system.

    Could you share with us briefly about your role as Chief of Medical Corps (CMC)? How has it been thus far since your appointment in May 2015?

    As the Chief of the SAF Medical Corps (CMC), I am overall responsible for the provision of quality healthcare services to all SAF servicemen and women and robust medical support to enable the SAF to conduct safe and realistic training.

    Since assuming the appointment of CMC in May 2015, I have had the privilege of setting the vision and driving the implementation of projects and initiatives to improve the quality of care and medical support provided to our servicemen and women. In April 2016, the 3rd generation of the SAF’s Electronic Medical Records System, known as the PAtient Care Enhancement System 3 or PACES 3, was rolled out. PACES 3 is an entirely new EMR system that connects seamlessly with Singapore’s National Electronic Health Records (NEHR) system. PACES 3 contains clinical decision support features and enhances patient safety by allowing the SAF to share allergy information and other key medical information with Singapore’s healthcare providers through the NEHR. Its user-friendly mobile eHealth portal has allowed our soldiers to conveniently book their own medical review appointments, retrieve information about their health visits and investigations, and enabled greater health ownership amongst our soldiers.

    In 2017, the SAF Medical Corps reviewed the SAF’s approach to the promotion of health. We collaborated with external partners such as the Health Promotion Board on useful national-level health initiatives such as the National Steps Challenge (Corporate) and introduction of healthier dietary choices for the SAF. The SAF Medical Corps also hosted the 3rd Asia Pacific Military Health Exchange, which saw more than 500 participants from the military medical services of Asia-Pacific nations gather in Singapore to share and learn from one another in the field of military medicine.

    We also enhanced our cooperation with the Singapore Civil Defence Force (SCDF), with the SAF Medical Corps embarking on a pilot partnership with the SCDF; 12 SAF medics were deployed to work alongside SCDF personnel on their ambulances for three months from October to December 2017.

    The SAF’s new Electronic Medical Records (EMR) System – PAtient Care Enhancement System (PACES) 3 was launched in April 2016 and was the winner of the “Digitalised Care to Support One Healthcare System” category at the National Health IT Excellence Awards 2017.

    Unlike its predecessors which was hosted internally on the SAF intranet, PACES 3 is now also connected to national healthcare systems such as the National Electronic Health Record (NEHR) and Critical Medical Information System (CMIS). What were some the considerations and challenges behind implementing an EMR that could easily integrate with other health systems/infrastructures?

    The key impetus for hosting PACES 3 on an Internet-facing platform was to integrate our medical care records with that of the national healthcare system. Introduced in 1995, PACES was upgraded to PACES 2 in 2005 to have networked capabilities over a secured intranet system.

    The Ministry of Health’s articulation of the national vision of “One Patient, One Record” and the introduction of the National Electronic Health Record (NEHR) in 2011 was a strong impetus for us to develop PACES 3 onto an Internet-facing platform that is integrated with the national healthcare system. This provided a seamless and safe transition of medical care between healthcare providers.

    The choice of the health IT solution and the partner agencies was a key consideration in the SAF’s EMR System. After an open tender and robust evaluation process, the SAF Medical Corps awarded the contract jointly to Allscripts and National Computer Systems (NCS). Prior to this partnership with the SAF, Allscripts had partnered Singhealth for their electronic medical records system and had a strong presence in Singapore, while NCS had worked with the SAF Medical Corps for both earlier versions of PACES.

    With PACES 3 on an Internet-facing platform, we had to ensure the security of the medical data. To address this challenge, the project team built in multiple layers of protection and defences to ensure the robustness of the system against cyber threats.

    A second challenge was the migration of 20 years’ worth of electronic medical records stored over the lifespan of PACES and PACES 2, to PACES 3. The project team worked closely with our vendors to ensure the fidelity of data transfer as this was important in patient care and safety.

    Looking to the future, even as PACES 3 was rolled out in April 2016, it is necessary to start thinking about PACES 4 and the next generation of EMR systems for the SAF. I am cognisant that PACES 3 will need to be upgraded or refreshed to meet the health needs of the SAF in the next decade. The SAF Medical Corps will keep abreast of the developments in medical IT through participation in relevant medical IT events and conferences, development of our people in medical IT literacy, and also putting in place a system of continual review and improvements.

    Are there any collaborations /projects between SAF and other medical organisations with regards to health IT?

    The SAF Medical Corps is currently in dialogue with the Singapore Ministry of Health to better understand the development and implementation of Smart Healthcare initiatives for Singapore. We want to ensure that the SAF’s future developments in medical IT continue to be aligned with the nation’s push towards Smart Healthcare.

    RADM (Dr) Tang Kong Choong is a speaker at the inaugural International Military Health IT (IMHIT) track at HIMSS AsiaPac 18 in Brisbane this November.

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    Epic has reduced the price for startups to participate in its App Orchard developer program and revealed a new entry-level tier.

    The new option, dubbed Nursery, costs $100 a year. Epic also said it has cut the pricing on its three existing tier by 33-80 percent.

    WHY IT MATTERS

    When electronic health record vendors first started launching developer programs, the going rate was usually to charge 30 percent of top line revenue. In the time since, however, companies have realized that is too steep for startups trying to decide whether they should write new apps for, say, Allscripts, athenahealth, Cerner, eClinicalWorks or Epic. Other EHR vendors have also restructured their pricing, accordingly.

    Nursery, for its part, provides fledgling innovators access to public API documentation, developer sandboxes for testing code, FHIR, Smart on FHIR and the CDS Hooks API.

    Nursery is for testing apps. “When a company is ready to go to market it can graduate to the next tier,” said Epic App Orchard Director Brett Gann.

    ON THE RECORD

    “These updates will help drive healthcare innovation as interested developers have the opportunity to build on top of Epic’s comprehensive health record platform, using emerging industry standards such as FHIR,” Gann explained.

    About that tem "comprehensive": Epic CEO Judy Faulkner said this past year that EHRs should now be called CHRs– as in comprehensive health records – reflecting that they incorporate more data types, such as social determinants of health. Epic’s chief rivals are moving in the same direction toward a CHR, regardless of what the software is named. (Other experts, meanwhile, have questioned whether "comprehensive" is even a goal to be striving for – preferring instead for records to be "connected.")

    OUR TAKE

    For our Focus on Innovation in Sept. 2018, we spoke with entrepreneurs about the challenges and opportunities of working with EHR vendor developer programs. High on the list of downsides: Pricing. That 30 percent of top line revenue inhibited innovation, many said.

    Fair and transparent pricing, in fact, is one of the seven tenets developers need from EHR vendors.

    Among the others: a playbook, clear terms of service, broader support for a single version of FHIR, business side process support and a truly open mindset more akin to Amazon than what exists today.

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

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    According to Executive Director PAH-QEII Network at Princess Alexandra Hospital, Dr Michael Cleary, the hospital was identified as a “lead site” in the early days of strategy for the implementation of software.

    The rollout involved two stages of implementation. The first stage was in 2015, involving the clinical records system but excluding the medications management, anaesthetics and research support (MARS) modules. The second phase occurred in 2017, adding over it the more complex components of the modules that were initially left out.

    In March 2017, as the Princess Alexandra Hospital rolled out the MARS system release, it marked its place as the first hospital in Queensland, Australia with advanced ieMR capability.

    “We were implementing software that needed to be tested and have gone through all the usual processes for assessment, validation for workflow, etc,” Cleary said.

    “We were looking at how it would work in the Queensland environment, within a hospital system and we felt that it was safer to roll out all the base level systems and then put the rest in as a secondary step.”

    And it was not treated as any ordinary ICT implementation.

    “We had a different strategy – our approach was to drive this as a clinical implementation instead of as an ICT implementation because of its enormous clinical requirement. Everything revolved around improvements in patient care and maintaining patient safety and therefore, we had senior clinicians embedded in the project and process,” Cleary said.

    “For example, we had four specialists involved in various components. We had quite a number of pharmacists and clinicians embedded in the teams that were designing and developing the software, effectively looking at organisational change.”

    But the rollout didn’t come without its own set of challenges.

    “Very often, we had to re-engineer the way clinical systems were operating. For example, we had to move to the universal application of insulin pens, moving away from historical insulin injections,” Cleary said.

    “We also had to replace our entire fleet of vital signs monitors so that we had devices that could be integrated with the systems.”

    The team persevered through the rollout, reaping flow-on benefits that revolved around integration capabilities for a closed loop of applications.

    “We’ve seen improvements in our data management, in terms of information and reporting. That has also led to changes including drawing information out of the Electronic Records System and the development of information tiles that provide a detailed summary of a particular type of illness or condition,” he said.

    “These information tiles form the basis of the operations of our command centre in the hospital, around patient safety, informed clinicians, and operational management.    

    “The information we’re receiving is almost real-time, as opposed to weeks or months before a report is extracted or presented to us. This lets us make practical, real-time decisions instead of reflecting on historical data and having to infer on what might needs to be done. Our digital transparency has improved as well.”

    In addition, the new systems have reduced the administrative workload on nurses, allowing them to spend more time with patients.

    The success of the rollout for Princess Alexandra Hospital resulted in a project to digitise medical records at four other hospitals – Logan, QEII Jubilee, Redland and Beaudesert hospitals – using ieMR.

    “As a consequence of the rollout at Princess Alexandra, over the last three years, we’ve implemented the same stack and systems and dominoed the same processes at these four hospitals,” Cleary said.

    The deployment at these five hospitals recently resulted in Queensland’s Metro South Health cementing its reputation for trailblazing digital health innovation by being recognised as a global leader at the International Hospital Federation Awards.

    Queensland Health aims to deliver ieMR with advanced capability to a total of 27 sites by June 2020.

    This article first appeared on Healthcare IT News Australia.

    As part of HIMSS AsiaPac18 in Brisbane in November, the conference is offering a hospital tour of the Princess Alexandra Hospital. Learn more here.

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    In an earnings call to discuss its Q3 results this past week, officials from Cerner offered new information about the ongoing electronic health record modernizations it's rolling out at the U.S. Departments of Defense and Veterans Affairs.

    Both are proceding at different paces, they said, but valuable lessons are being learned along the way at each.

    After initial deployments at four DoD sites in the Pacific Northwest that saw their share of hiccups, MHS Genesis is ready for the next wave of installs at four more Air Force and Navy sites on the West Coast, said John Peterzalek, Cerner's chief client officer. "We believe these sites will benefit from the optimization efforts that followed our initial go-lives," he said.

    As for the VA, Cerner is "on track to steadily ramp our work on the project as we finish 2018 and move into 2019," he added. "The first major project milestone will be in 2020, when initial sites are scheduled to go-live."

    "We're pretty early in that process," added Marc Naughton, Cerner's chief financial officer. "But once it really cranks up, we're still a little early on deciding exactly what share that we'll perform and what share our partners will perform." He explained that the ramps-up "is not necessarily going to be linear. It could be a little bit lumpy depending on what work is being done, kind of slower start. And then once it gets up to scale, there's a lot to go do."

    Change management is key, says DoD lead

    In a podcast posted to the Cerner website on Monday, Stacy Cummings, program executive officer for Defense Healthcare Management Systems, who's overseeing the MHS Genesis implementation.

    As the rollout moves next past its initial operational capability phase in Washington State, Cummings said there have been some valuable lessons learned about EHR configuration, workflow, change management, training and adoption that will be brought to the next stages of the project.

    One of the big ones, she said, is that "you need to make sure you have a good network infrastructure in place for MHS Genesis to be as reliable and speedy and efficient as possible." At first, she explained, IOC sites didn't leave enough time between ensuring network stability going live with the EHR, and that posed some big challenges.

    Along with having a robust network, "cybersecurity is so important," said Cummings, who said the top priorities for MHS Genesis are "patient safety and keeping patient's data secure."

    But perhaps the biggest takeaway from the first stage of the project, learned the hard way as many clinicians struggled with new technology and new workflows, is the importance of change management and training, she said.

    "Our original change management and training structure focused a little too much on how to use the system and not enough on how the workflow will differ from legacy, where it was a lot more based on putting content into the system, to MHS Genesis, which is really a workflow-based, role-based system," said Cummings.

    From the Pacific Northwest, the next step is to moving down the coast, with new Cerner rollouts at four new bases in California, she said: Travis Air Force Base (the largest of the four), Mountain Home AFB, Lemoore Naval Air Station and Monterey AFB.

    The projects will build on the successes already occurring at the IOC sites – Cummings mentioned high uptake of patient portal and secure messaging, barcoding compliance at 85 percent and a tightly integrated inpatient-outpatient ED system – but will also incorporate some hard-earned wisdom from some of the challenges faced in Bremerton, Fairchild, Madigan and Oak Harbor.

    "We're really looking at our network stability schedule and basing our schedule on that," rather than vice versa, she explained. "With network stability for six months. We'll be able to use the system during training the same way we'll be able to use it when we're actually operational."

    And when it comes to change management, lessons learned from the pilot sites will be crucial., said Cummings. But "not just to apply them and move on," she said. "Apply them and test again. See where we got it perfect, and where we need to do a little more work to make it the best possible solution for our users and our beneficiaries."

    At VA, hard work gets under way

    In a blog post Tuesday, Travis Dalton, president of Cerner Government Services, gave his own update on MHS Genesis – he pointed to efforts to "identify challenges and fine-tune processes early," working with the DoD’s Joint Interoperable Test Command – and also indicated that some of those learnings will be applied to the rollout at the VA.

    "Cerner and the agency are committed to applying commercial best practices, as well as any lessons learned from our DoD experience, to the VA’s Electronic Health Record Modernization program," said Dalton. "The VA has unique challenges and it’s critical that end-users and stakeholders are engaged throughout the implementation process."

    As for next steps, he said the wisdom gleaned from the DoD project has left Cerner well-positioned for the VA rollout, where the "work is only beginning."

    Cerner is "continually engaging their leaders and end-users through local workshops and site reviews that are critical to implementation at their IOC sites," said Dalton. The modernization project will "have ongoing innovation and health information exchanges among military and Veteran care facilities and thousands of civilian health care providers throughout the program."

    It's been three years since work began in earnest on MHS Genesis. Now that Cerner is getting down to brass tacks on the VA project too, the company is clear-eyed about the large task it (and its partner, Leidos Partnership for Defense Health) faces.

    "We know the commitment a complex IT installation requires," said Dalton. "We also know that there will be hurdles to overcome."

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    As is the case with many EHR implementations, the road to roll out has not been an easy one for New York City Health + Hospitals, the largest public health system in the country.

    Which is not entirely surprising given the project’s scope: NYC H+H is undergoing one of the largest Epic implementations in the country that will ultimately unify 40,000 users in more than 70 patient care sites.

    The initiative was among the first to launch with both a customized electronic health record system and revenue cycle modules. It also put NYC H+H in the league of EHR go-lives with a budget that surpassed $1 billion. Earlier this year, in fact, the Mayo Clinic CIO Christopher Ross discussed it's $1.5 billion EHR and IT modernization replacing Cerner and GE with Epic. 

    NYC H+H, in fact, announced the launch of its Epic EHR and rev cycle tools, dubbed H20 by staff abbreviating Health+Hospitals Online, into a production environment at its Woodhull facility and 10 community health centers and clinics in Brooklyn.

    While the system said the implementation and subsequent testing went smoothly, the road wasn’t always pothole-free for the Epic project. Here’s a look back at the ups and downs of the project’s past as it steams ahead towards full implementation, slated for the last quarter of 2020.

    March 2016: CMIO steps down citing patient safety issues

    Charles Perry, the CMIO for the system’s Queens and Elmurst hospitals, resigned his post reportedly over safety concerns surrounding the Epic EHR rollout and potential implications for patient safety and harm. While Perry told Healthcare IT News that he had no comment, two posts on a whistleblower blog site that included purported email exchanges between system executives including Perry indicated that there were serious concerns about the rollout, saying it was introducing “grave patient safety risks” as it strained to meet the rollout deadline and that a crash was inevitable.

    NYC H+H fired back, saying it would not jeopardize patient safety simply to meet a deadline and that the project would stop if a patient safety issue was identified. Officials went on to say that a team of roughly 900 technicians would be working around the clock through the week of the first implementation to ensure a smooth transmission.

    April 2016: First Epic rollouts 

    NYC H+H rolled out the first Epic electronic medical record system on April 2, 2016, at two hospitals: NYC Health + Hospitals/Elmhurst and NYC Health + Hospitals/Queens as well as the 20 off-site neighborhood health centers  affiliated with the two hospitals and the system’s home care service.

    February 2017: Delay and next go-live

    However, this month also saw the delay of the next big phase of the rollout by several months to take into account insights gleaned from the first phase of the implementation, saying they were moving ahead at the “appropriate pace to ensure the best possible result for patients and providers.”

    The system declined to specify what those insights were, but said the project was still on budget. 

    The next go-live, meanwhile, went forward on February 25, 2017, at NYC Health + Hospitals/Coney Island.

    May 2017: Integrate EHR with rev cycle

    NYC H+H announced a plan to integrate an Epic revenue cycle module into its EHR. The price of the project, which started out at $764 million for the EHR, would grow by $289 million with the additional cost of the revenue cycle module. That price tag would be an investment over five years as it is fully implemented. The city of New York was expected to allocate $150 million in capital funds and the system would invest $139 million from its operating costs.

    At the time, H+H said they expected the rev cycle software to capture $142 million in added annual revenue, based on patient volume for 2016. They also said the revenue cycle system would improve clinical documentation to support billed services, cut claims denials and speed up reimbursements.

    December 2017: New CIO and President come onboard

    Kevin Lynch, a healthcare IT leader for 25 years and the soon-to-be-former CIO for LA County’s Department of Health and Human Services, is tapped to be H+H’s new CIO. Lynch had served as CIO in LA County since 2010, and notably, oversaw the implementation of its enterprise wide EHR from a fragmented clinical IT system. In a former role as a corporate director at Jackson Health System in Miami-Dade County, he did the same. LA County is the second largest public health system in the country after H+H and Jackson is often ranked third.

    H+H president and CEO Mitchell Katz formerly headed of LA County’s Department of Health, asked Lynch to come aboard. Both of their tenures began in January 2018.

    October 2018: Big EHR go-live

    NYC Health + Hospitals announced the launch its Woodhull and 10 community health centers and neighborhood clinics in Brooklyn. This was the first implementation of the integrated EHR system that included both the clinical and revenue cycle modules.

    At the same time, the system retrofitted the already installed electronic medical record systems at its Coney Island, Elmhurst, and Queens hospitals along with another 15 health centers and neighborhood clinics in Queens and Brooklyn with the new revenue cycle module.

    The four hospitals and 25 community-based ambulatory care sites mean that 14,000 active users will now be working with the new EHR system.

    “Successful implementations are possible only following an incredible amount of planning and hard work,” said Lynch. “We have diligently created a good design-build-test-train-and-implementation process that has resulted in this effort. We see our energetic, enthusiastic staff using H2O effectively to provide patient care.”

    The new integrated EHR system features Epic’s patient portal MyChart, giving patients digital access to their medical records and the ability to view medical test results, request prescription refills, send messages to the care team, and access appointment information.  

    It also includes decision-support tools that equip providers with alerts to prevent medication errors, avoid duplicative and unnecessary tests, and keep patients preventive health screenings on schedule.

    The revenue cycle module enables more simplified billing as items are recognized as billable at the time they are ordered. It paves the way for population health efforts with more refined data on clinical groupings of patients.

    NYC H+H's next scheduled launch is in spring 2019 at its Bellevue and Harlem hospitals as well as 19 community health centers and neighborhood clinics in Manhattan. 

    Twitter: @BethJSanborn
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    Cambridge University Hospitals NHS Foundation Trust (CUH) has become the first NHS trust and the first Global Digital Exemplar (GDE) to be revalidated against the new Stage 6 HIMSS Analytics international Electronic Medical Record Adoption Model (EMRAM) standards that came into force at the beginning of the year.

    The changes were designed to reflect progress in the healthcare technology and information space during the past few years, with the Picture Archiving and Communication System (PACS) requirement, for instance, moved from higher to lower stages of the model (PACS is now part of the Stage 1 criteria, as opposed to Stage 5).

    New standards were also introduced to ensure that cybersecurity and disaster recovery were “fully recognised as important factors in a modern health service”, John Rayner, Regional Director for Europe and Latin America, HIMSS Analytics, told Healthcare IT News.

    “In addition, areas of compliance have been increased to raise the bar and to acknowledge the importance of having these critical services hospital-wide, rather than in a single clinical area. As a result of these changes, some hospitals are likely to find achieving the higher stages of the model more challenging than they did prior to January 2018,” Rayner said.

    Cambridge University Hospitals went live with Epic back in 2014

    CUH, which runs Addenbrooke’s Hospital and The Rosie, originally achieved Stage 6 of the EMRAM standards back in 2015, following the creation of its eHospital digital transformation programme.

    The HITN team visited CUH more than four years after the “big bang” go-live of their Epic EPR,  configured during an 18-month period to incorporate the trust’s clinical workflows and to support local and national guidelines, and found overwhelming support for its digital agenda. Their EPR is now reportedly being used by around 3,400 staff at peak times across all clinical areas, and Luke Bage, Senior Charge Nurse, told HITN that the system “continually seems to improve”. 

    “The Epic that you see at the beginning of the year is not the same Epic that you see at the end of the year,” said Dr Afzal Chaudhry, Renal Consultant and Chief Clinical Information Officer (CCIO) at the trust.

    After developing electronic early warning alerts within the EPR, launched in their Emergency Department in 2016 and across all adult inpatient areas at both hospitals in 2017 to ensure that nurses and doctors are notified if a patient’s clinical observations meet sepsis criteria, the trust has seen a 42 per cent reduction in sepsis mortality.

    In April this year, CUH linked Epic to the Cerner Millennium system used at West Suffolk NHS Foundation Trust, helping clinicians securely access clinical information about a patient held within each other’s EPR to improve quality of care, as figures show that nearly 30 per cent of their patients attend both trusts for treatment.

    The next month, through a digital primary care portal called EpicCare Link, a similar initiative was launched to help GPs and community nurses securely access clinical information about their patients from within the Epic EPR, currently available at Granta Medical Practices in Cambridgeshire.

    The Care Everywhere HIE functionality also connects CUH to Epic hospitals around the world and, once University College London Hospitals NHS Foundation Trust and Great Ormond Street Hospital for Children NHS Foundation Trust go live with Epic next spring, the trust will also be connected to them.

    CUH wants to become the first trust to reach EMRAM Stage 7 in the UK

    Meanwhile, CUH signed a £107m seven-year contract with Novosco in June to replace and strengthen its infrastructure to take account of “more mobile working, device integration, and accommodate telemedicine, whilst keeping the system secure, protected, and accessible”, according to Chaudhry. The transition process is underway, and the trust now has an ambition to reach Stage 7 of the EMRAM. 

    “The main things that we would like to focus on are a robust methodology for quality improvement informed by the use of data, so that we’ve got real data-driven analytics to help us understand where we have the greatest opportunities to improve patient care and to measure the beneficial outcomes of that in a sort of continuous improvement cycle,” Chaudhry said.

    Commenting on today's announcement, Dr Ewen Cameron, CUH Executive Director of Improvement and Transformation, added:

    “To validate against the new criteria shows how far we have come over the years since we implemented Epic and since our last HIMSS inspection. Our aim now is to further advance our use of technology to provide even greater benefits to our patients and staff and, as a result of doing this, become the first Stage 7 trust in the UK.”

    Only two other organisations have previously reached Stage 6 of the EMRAM in the UK, Kingston Hospital NHS Foundation Trust and St George's University Hospital NHS Foundation Trust.

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    Ten UK health tech start-ups to receive £40,000 through KQ accelerator

    Ten UK start-ups working at the intersection of biomedical and data science have now been selected to take part in the £400,000, 16-week KQ (Knowledge Quarter) Labs accelerator run by the Francis Crick Institute in London, meant to speed up development and adoption of data-driven technologies addressing global health challenges.

    Vision Game Labs, which is creating home-monitoring and remote-diagnosis vision kits for smartphones, using gaming techniques to gather visual data and diagnose eye disease, is one of the start-ups that will receive £40,000 to validate their business proposals through the programme, which is funded by Innovate UK, before looking for further investment.

    “The start-ups all have the potential to make an impact on global health outcomes and will have access to unrivaled support and resources.

    “These ventures will help shape the future of health in a sector that is a vital part of the government’s modern Industrial Strategy,” said Chris Sawyer, Innovation Lead, Digital Health at Innovate UK.

    Ireland’s largest acute hospital finalises Cerner Millennium implementation

    Ireland’s St James’s Hospital has now completed the rollout of the Cerner EPR, with every inpatient specialty and department going live with upgraded Millennium functionality in a programme labelled “Project Oak” – referencing the move away from paper-based processes.

    The functionality is set to reduce duplication and allow quicker access to clinical information, with 2,400 staff members receiving more than 21,000 hours of training ahead of the implementation, according to the supplier.

    “We are in the early stages of the launch, but careful planning has ensured that patient care has not been disrupted significantly over the weekend,” said Dr. Gráinne Courtney, Chief Clinical Information Officer at St James’s Hospital.

    “The implementation of this system is set to bring a raft of benefits to patients attending the hospital as health records are available instantly to those caring for a patient. Increased efficiencies mean patients will wait less time for their diagnoses, treatments and care. Over the course of the coming months and years we anticipate this will translate into shorter wait times and hospital stays.”

    HITN sister publication MobiHealthNews reported last month that the European Investment Bank was backing the implementation of Ireland’s eHealth programme with a €225m loan to support the creation of a “modern patient-centred health service”, according to Health Minister Simon Harris.

    NHS trust goes live with Patient Administration System

    East Kent Hospitals University NHS Foundation Trust has gone live with an Allscripts Patient Administration System (PAS) in a project that involved the migration of 42 million records to the new system. The trust runs five hospitals and community clinics, providing a range of services to a local population of around 695,000 people.

    “Deploying a new PAS is a major undertaking, but our old system was outdated and we had to change it to move onto the next stage of our IT development," said Andy Barker, East Kent Hospitals IT Director. "The Allscripts PAS gives us the platform to move forward with an electronic patient record."

    East Kent Hospitals ran a joint procurement for a new PAS with Maidstone and Tunbridge Wells NHS Trust back in 2015. Both trusts will now be deploying the Allscripts Sunrise EPR. Maidstone and Tunbridge Wells went live with the Allscripts PAS in 2017.

    Neurology advice line for GPs saves the NHS £100,000 a year

    An advice line run by the Walton Centre, a specialist hospital trust, in Liverpool, enabling GPs in the north west of England to call neuro consultants for advice, reducing the need for additional appointments, is saving the NHS £100,000 a year. According to NHS England, nearly 40 per cent of 181 calls received in 2017-18 were solved by GPs, saving around £52,000.

    Karen Kirkham, NHS England National Clinical Advisor for Primary Care, said the NHS would be looking to scale up similar innovations, with a long-term plan expected to be published later this year.

    “The Walton Centre’s advice line is an example of integrated care in action, connecting GPs with hospital specialists to provide more joined up care for patients. We often find these kind of improvements also make savings that can be reinvested back into the local NHS.

    “In this case patients also need less time off work because they need fewer appointments and to travel less, which is also good for the environment,” Kirkham added.

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    The global market for electronic health records is as diverse and far-flung as the countries and cultures served by the technology. Different regions are at different levels in their IT maturity, have different historical preferences for certain vendors, and have different healthcare imperatives they're trying to solve.

    The new Global EMR Performance 2018 report from KLAS arrives just as the EMR market is burgeoning in a big way around the world, and aims to address vendor performance by specific regions to offer accurate picture of how regional and multiregional companies are delivering for their provider customers in each area.

    WHY IT MATTERS
    KLAS notes that the size and scale of IT deployments have generally grown significantly worldwide in recent years, "rapidly changing the global EMR landscape."

    The new report, drawing on provider feedback from 365 inpatient providers worldwide over 18 months, aims to offer an "accurate picture of how vendors respond to regional needs," gauging "how confident customers are in their vendor’s overall R&D efforts, in their dedication to healthcare in various regions, and in their ability to strategically partner with organizations to help drive deeper EMR adoption."

    The report examines the performance of smaller, more localized players such as Agfa HealthCare, Cambio, ChipSoft, Dedalus (Medasys), DXC Technology's Lorenzo, everis, MV SOUL, Philips Tasy Java and Tieto.

    But the largest, multiregional vendors, many of them gaining traction in competitive markets abroad based in part on their reputations here in the States, are American names we all recognize.

    Epic is still new to many regions, for instance, but 75 percent of responding organizations worldwide reported high overall satisfaction. Cerner, as the only company on the list with installs in all corners of the world, also has above-average satisfaction. Some vendors look to be focusing on honing their perform in certain international regions, such as Meditech in Canada and the UK & Ireland.

    THE LARGER TREND
    The global EMR market varies "significantly by region in terms of both market share and performance," according to the KLAS report. "Multiregional vendors may have large customer bases in certain regions and none in others, and they may perform much better in some regions than they do elsewhere."

    While there is currently no vendor broadly deployed in all regions with high customer satisfaction across all of them, researchers said, some regions have different preferences than others.

    Canada. Meditech has been a longtime player north of the border and has generally earned high marks for meeting "Canada-specific needs," said KLAS. Its recently launched Expanse platform "will be critical for long-term customers on legacy platforms, who need updated technology to meet market demands." Cerner does OK in Canada, according to the report, but customers in Canada often report feeling that they get "US-focused rather than Canada-specific functionality." Allscripts has recently reaffirmed its commitment to our neighbor to the north, and researchers say it's working to develop more localized functionality as customers, broadly speaking, see better strategic engagement.

    Europe. Generally, speaking, European customers had positive reviews of Epic's "commitment to the region and strong executive relationships," said KLAS researchers, who nonetheless noted that the company "can miss market nuances, potentially slowing their regional growth." Cerner has boosted its relationship with Millennium customers and, likewise, their confidence in its R&D efforts, even if it wasn't always quick to respond to region-specific change requests. InterSystems has made quick inroads across Europe, but is having "development and implementation issues," according to the report. Meanwhile, despite specific challenges for each, Agfa HealthCare, Cambio, ChipSoft, and Dedalus (Medasys) get high marks based on their customers' confidence in their R&D and regional dedication.

    Middle East. InterSystems has been a leader in the Middle East for years, but researchers find that "multiple concurrent implementations in the UAE have suffered from stretched resources, as have established customers to a lesser extent."  Cerner, on the other hand, the vendor with the most sizable market share in the region, "has demonstrated stable performance thanks to robust functionality and strong integration." Epic has three live customers in the region, who say they're very satisfied, but "also want to see a greater regional presence and improved regional expertise," according to KLAS.

    AsiacPac. "Cerner has steadily improved across the region in past years due to deepening adoption and the cloud functionality they recently made available in the region," according to the KLAS report. Meanwhile, InterSystems' performance has declined "substantially" researchers said, thanks to delivery challenges in Oceania that seem to stem from resource diversion challenges with a big Australian implementation. Still, its customers in Asia – China, Thailand –are "generally pleased."

    Latin America. MV and Philips are the biggest vendors in the region, but opinions on them have diverged over the past year, KLAS said. "MV’s ratings have improved slightly thanks to their easy-to-use product and ongoing investment in R&D," researchers said, pointing to strong executive relationships and guidance, but weak lower-level support. "Conversely, Philips’ scores have decreased. While the product itself has improved, specifically in stability, Philips’ efforts to grow outside of Brazil – where their Latin American customer base has historically been centered – have left Brazilian customers feeling forgotten."

    ON THE RECORD
    "Epic is a relative newcomer in many regions yet performs best in providing a consistently positive experience across regions thanks to strong partnerships and strategic guidance throughout the implementation process," KLAS researchers wrote.

    "Cerner is the only vendor with customers in every region and comes next in global performance and consistency," the researchers added. "While overall satisfaction is above average, customers say they have largely driven their own success. Cerner is willing to engage strategically, though generally not proactively and often at an extra cost."

    Meditech, meanwhile, "performs above average in Canada and the UK & Ireland thanks to more strategic engagements in recent years," according to the report, which raised concerns about the company's slow growth and development in those market. It also noted that Allscripts customers "have achieved deep adoption" but "often feel they drove their implementation themselves."

    And InterSystems has seen some market decline in recent years thanks to challenges related to its "inability to provide adequate staff to meet increasing regional demands," the report shows. "European customers report delayed implementations and stretched vendor resources, and customers in the Middle East and Australia experience similar challenges with new implementations and transitions to new country-specific EMR editions."

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    Epic has a new customer for its comprehensive health records system: Irvine, California-based Pacific Dental Services, which provides business and administrative services for dental offices.

    WHY IT MATTERS
    It's the first dental support organization to sign on with Epic. The implementation means that all healthcare organizations, including dentists and oral specialists supported by PDS, can use Epic technology can now readily exchange patient data for improved patient care.

    The rollout, which is expected to be completed by 2020, will boost care coordination and reduce duplication, according to Epic. Patients of those dental providers will have access to its MyChart patient portal, gaining secure digital access to their health information and the ability to schedule appointments and pay bills.

    "Poor oral health has been linked to cardiovascular disease, pregnancy and birth defects, and diabetes," said Alan Hutchison, vice president of population health at Epic. "Through the use of Care Everywhere, dentists across the country will have real-time access to important clinical information."

    THE LARGER TREND
    This is not Epic's first experience with dental records. Earlier this year, Columbia University College of Dental Medicine announced that it would launch a new Center for Precision Dental Medicine, which will leverage technology for data-driven research into links between dental and overall health.

    The college is among the first academic dental institutions to unify dental and medical patient records in Epic, enabling them to be shared among clinicians at Columbia, NewYork-Presbyterian and Weill Cornell Medicine.

    ON THE RECORD
    "Oral healthcare is a critical component of overall health and this investment will enable PDS-supported clinicians and their patients to more fully participate in the promise of a seamless, comprehensive healthcare system focused on whole body health," said Stephen E. Thorne, IV, founder and CEO of Pacific Dental Services, in a statement.

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    Athenahealth is set to be acquired by Veritas Capital and Evergreen Coast Capital for $5.7 billion.

    Together, Veritas and Evergreen, the private equity subsidiary of Elliott Management, the hedge fund that has actively urged athenahealth to sell for more than a year, will pay $135 per share for the cloud IT company – about 12 percent more than its valuation at the close of trading this past Friday.

    WHY IT MATTERS
    The deal brings to a resolution a matter that has been much discussed over the past two years. Elliott, which had a 9 percent ownership position in the firm, had pressured the Watertown, Massachusetts-based company to sell since 2017, claiming it could to better with operational efficiencies that would maximize shareholder value.

    Upon completion of the acquisition, which has been unanimously approved by the athenahealth board and is expected to close in the first quarter of 2019, Veritas and Evergreen plan to combine athenahealth with Virence Health, the former value-based care group of GE Healthcare that was bought by Veritas this years.

    Together the companies, operating under the athenahealth brand, will continue developing technologies to help provider customers succeed in the era of accountable care, officials said.

    The company will be led by Virence Chairman and CEO Bob Segert, as well as executives from both firms. (Upon the deal's completion, Virence's Workforce Management business will become a separate Veritas portfolio company under the API Healthcare brand.)

    THE LARGER TREND
    Since 2017, athenahealth has undergone a major restructuring, hired ex-GE chief exec Jeff Immelt as chairman, seen its founding CEO step down amid allegations of past abuse, laid off hundreds of workers and sold its corporate jet.

    Veritas has been in buying mode for health IT companies recently, including its Verscend Technologies subsidiary's aquisition of Cotiviti  this summer.

    ON THE RECORD
    Jeff Immelt, executive chairman of athenahealth, said the deal "maximizes value for our shareholders and accelerates our goal to transform healthcare." By joining with Virence, athenahealth "will create new opportunities for collaboration and growth," he added. "Operating as a private company with Veritas's ownership and support will provide athenahealth with increased flexibility to achieve our purpose of unleashing our collective potential to transform healthcare."

    "We are excited by the opportunity to partner with athenahealth, one of the largest and most connected provider networks in the nation, to drive outcomes that matter the most to our customers," added Virence CEO Bob Segert. "athenahealth and Virence have complementary portfolios and highly-talented people, and this combination expands our depth and reach across the continuum of care. I'm looking forward to combining our mission-driven cultures to create an even stronger healthcare IT company."

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    Setting the context regarding military health systems for the broad audience who may not have direct experience with them or understand how they work, Dr Charles Alessi, Chief Clinical Officer, HIMSS, who is also the moderator of the IMHIT panel on Day Two of the conference, explained that the populations in military health systems are not necessarily very old compared to civilian ones and not necessarily multi-morbid.

    “There are a unique set of circumstances – firstly, there are the occupational health requirements in military health which are really very different to what you expect to find in civilian life. Secondly, care often has to be delivered in small, isolated communities and that in itself poses some significant challenges, often associated with clinical governors ensuring that clinicians that look after that population are in the right system and are really following guidance in the appropriate way.

    When military personnel go to places on their own, they need systems of governance which are really quite robust,” said Dr Alessi.

    He also added that are very unique challenges in terms of information exchange for military personnel and military systems. One of them is the fact that interoperability is as much of a problem in military health as it is within civilian life. Secondly, integration is a significant issue, such as integrating information back into civilian registers. The last challenge is cybersecurity, given the dangers associated with people being able to see the information and operating in environments where the Internet infrastructure may not be optimal.

    The top two challenges and priorities in a military environment

    “Security and the interoperability are the two main challenges, and interoperability because in the garrison environment, which is what we call healthcare in Australia on (military) bases. We have healthcare on bases but our personnel would also have to use civilian health systems as well, both private and public hospitals. The challenge for us is to be able run our system, which is a system within the Australian healthcare system, isolated but able to connect to those other environments as well.

    But if we go overseas, we often work in parallel with both nations here in various missions – we have Australians, Singaporeans, British and vice-versa, how do we then ‘talk’ to those systems as well? How do we ensure the oversight and security of those information?” replied Air-Vice Marshal Tracy Smart, Surgeon General, Australian Defence Force.

    Rear Admiral (Dr) Tang Kong Choong, Chief of Medical Corps, Singapore Armed Forces (SAF), expressed similar concerns: “Cybersecurity is also a big challenge of the SAF when implementing the military health IT system within the military IT system, and there are standards to be met. That was interesting because when we tried to integrate our military health IT system with the national healthcare IT system, there were a lot of challenges because we had to meet those stringent security requirements and it took a lot of time to do testing and vulnerability assessments.”

    The other challenge that Rear Admiral (Dr) Tang mentioned was the personnel within the military that had the expertise to develop the health IT track that they are now looking at. Traditionally, the SAF does not develop staff in these areas of expertise, so it is about looking outward at how to better grow their people and maybe even bring in external experts who can advise on how to do things better.

    “From our perspective, the main challenge of coming up with a fully-functional and deployable model is to clarify the taxonomy of that so we can actually operate on a global basis in austere environments and we can be part of that whole command decision-making chain so that we can garner and collectively use our data.

    The second challenge for us is a truly, fully integrated electronic healthcare records. We have a complex situation as we not only have four nations to deal with but within England particularly, the NHS has multiple different systems as well. So actually trying to achieve a fully integrated EHR within the UK is a challenge,” said Air Vice-Marshal Alastair Reid, Defence Medical Director, HQ Surgeon General, Ministry of Defence, United Kingdom.

    Key benefits that military health systems can gain from health information exchange

    Due to Singapore’s relatively small defence force, Rear Admiral (Dr) Tang said that the SAF does not run hospitals so the specialist care that is required for the service staff would be provided by (civilian) hospitals. Because of that, there can be a potential gap of knowledge of not knowing what happened to that service staff while he or she is in hospital, so that is where the integration of the National Electronic Health Record (NEHR) system has been very useful. SAF medical staff can access that information from their own EMR system through a contact switch and see what the service staff has undergone in terms of procedures, prior diagnoses as well medications that were prescribed.

    “That gives us a very good understanding of the whole spectrum of care from the time the person has been referred till he or she has recovered, we are able to get that information through the integration with the NEHR,” he added.

    For Lt Col David Bullock, Deputy Director, Health Knowledge Management, Information Warfare Division, Joint Capabilities Group, Australian Defence Force, Australia, the real benefits from health information exchange in the military and digitisation of the defence force lie in the data generated from service staff that can be used for predictive and prescriptive models of care using analytics. For instance, studying the data and trends can potentially help reduce common injuries that happen to service staff. With that, the related risks can be understood better from an epidemiological profile, which allows for the provision of smarter training regimes.

    “One of the real benefits that we got out of our e-Health system that we put in place in 2014 is data that we never had before. That data has really driven major efficiencies – over the course of the contract that we signed in 2012 to enable our services has saved us 51 million dollars over time. We are now actually able to compare per capita costs with the Australian population and it is not a big difference compared to the civilian population. It can drive better understanding of business even with that premium and a better way to deliver healthcare.

    It just allows us to do our job better and our job is both caring for our people as healthcare providers and also enabling their operational capabilities. So it enables us to be better across the board from prevention, protection, treatment to then recovery and also transitioning them to their new life as a civilian post-service,” shared Air-Vice Marshal Smart.

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    Hospital IT executives in Europe share many of the same priorities and face many similar challenges as CIOs in other regions of the globe, including the United States, according to the HIMSS Analytics Annual European eHealth Survey 2018 released on Wednesday.

    Among them: empowering patients, sharing health information, protecting sensitive data and managing the growing need for a deeper talent pool.

    WHY IT MATTERS

    Healthcare entities around the globe are all facing what is essentially the same set of opportunities and challenges in digital transformation.  

    Whether you call it patient experience, engagement or empowerment, HIMSS Analytics found that consumers owning and managing their own data, whether in apps or wearables, is a high priority among the 571 health information and technology professionals who participated in the survey.

    "The level of achievement varies," said Jorg Studzinki, director of research and advisory services at HIMSS Analytics. "While countries like Germany and Switzerland need better and more electronic patient records, other ones, especially the Nordics and the Netherlands, can already change their focus toward more innovative ways to provide care, create networks of collaboration and let the patient actively participate in managing more aspects of self-care and prevention."

    To that end, HIMSS Analytics listed EMR-maturity as a factor for advancing eHealth projects, as is the ability to share health data.

    "In the second wave of digitization, healthcare has to move toward a shared care model," said Jordi Piera, chief information and R&D officer at Badalona Serveis Assistencials, member of the Global Conference Education Committee at HIMSS and secretary of the strategic IT board at the Catalonian Healthcare Department. "Patients should be able to receive all types of care in their prefered location," he added. "This will, in turn, increase the efficiency and sustainability of our organizations."

    Enabling that shared care model will also require strong cybersecurity in the age of consumerism. HIMSS Analytics research found that operating with insufficient budget for infosec will continue to be a large challenge for hospitals and healthcare entities in the years ahead – and that is true even though attacks grow increasingly sophisticated.

    "Public healthcare institutions are regularly attacked by hackers and often they lose valuable information," Piera said. "We need to put a greater emphasis on protecting our systems; the number of cyberattacks is on the rise and our IT infrastructures and staff are not ready for them. Furthermore the number of patient devices connected to the systems is growing and this poses even greater risks."

    WHAT COMES NEXT: NEED FOR NEW TECH TALENT

    Empowering patients, achieving interoperability and securing health information fueling the need for new skill sets and, as such, giving rise to emerging career roles.

    "While a few years ago it was often sufficient to put digital transformation into the hands of a CIO or an IT director, this is not enough anymore," Studzinki said. "Chief digital officers and chief innovation officers appear in more organizations, especially in larger ones. And it is likely that we will see even more of this differentiation of job roles in the future." 

     

    Focus on Artificial Intelligence

    In November, we take a deep dive into AI and machine learning.

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

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    CommonWell Health Alliance has made Carequality Framework connectivity generally available to its members, which will "break down yet another barrier to interoperability," said CommonWell executive director Jitin Asnaani.

    WHY IT MATTERS
    Providers who participate in CommonWell and Carequality will be able to connect to each other  and bilaterally exchange health data for better care coordination and clinical decision-making officials said.

    CommonWell service provider Change Healthcare built the infrastructure, and Cerner and Greenway Health used it to roll out connectivity pilot this July with some of their clients, who in turn have been exchanging data with other Carequality-enabled providers. Since the summer, more than 200,000 documents with Carequality-enabled providers have been exchanged bilaterally nationwide.

    Now other CommonWell members are building off that successful connection, such as Brightree, Evident and MEDITECH, are in the process of subscribing to the connection and taking it live with their provider clients.

    THE LARGER TREND
    The two groups, who have been working together since 2016, said this news is a milestone on the long road toward more seamless interoperability – advancing the mission of making health data available to individuals and providers regardless where care occurs.

    In July, Massachusetts eHealth Collaborative CEO Micky Tripathi, who is on the board of both CommonWell and The Sequoia Project (which oversees Carequality), said the go-live of a nationwide health information exchange, encompassing all the big EHR vendors, enabling about 80 percent of doctors to share patient data, "will be a signature moment in nationwide interoperability."

    Tripathi said he's "very sanguine about where interoperability is and where it's headed. You can decide whether that means I'm biased or bullish, but I think it's more the latter."

    ON THE RECORD
    In press statements, CommonWell and Carequality offered perspective from several of their leading provider members. For instance, Michael Donnenwerth, a podiatrist at Minnosota-based Winona Health, a Cerner client, said the connection enables to clinic to directly access patient records from various tertiary care centers in the region.

    "We are now able to integrate new medications and problems into our EHR seamlessly, which provides the most accurate and up-to-date information possible," said Donnenwerth. "This flow of information has not only connected our medical records, but it has allowed us to truly provide better care as the ambiguity of outside doctor visits has been virtually eliminated."

    "Now that we’re able to get patient information across disparate providers through the CommonWell-Carequality Connection, I think it will reduce hospital readmissions," added Roneisha Ward, director of health IT at Carolina Family Health Centers, a Greenway Health client.

    "By knowing what was done on the other end, we aren’t duplicating work in labs and referrals and patients don’t have to spend lots of time and money outside of the clinic," she added. "It’s a win-win for the patient, the organization and the hospitals."

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    In the decade-and-a-half since the startling “To Err is Human” report, it’s still hard to discern whether billions invested in electronic medical records are improving patient safety.

    Health systems have made significant investments in digitizing their operations primarily through the deployment of the electronic medical record (EMR). The EMR platform, in fact, holds the promise of being the foundation to address the many clinical shortfalls documented in the Institute of Medicine (IOM) 1999 landmark report “To Err is Human: Building a Safer Health System.”  

    The report identified that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors. The source for a significant percentage of these errors is the lack of appropriate patient data available to clinicians at the point of patient care.

    With more than 15 years since the IOM report, the question is: “Have these EMR investments made a difference in reducing the reported eye-opening outcomes?" 

    It’s an important question to ask and like most in our industry, I’m not completely sure of the answer. A quick scan of the internet identifies multiple articles on the topic that are fairly dated and often speak to the promise of the EMR along with the barriers to adoption. 

    Logically, it's sensible to think that having patient data aggregated and distributed freely across a health system as well as to other caregivers should be beneficial to patient care. It’s also sensible to believe that in today’s environment of complex regulation, personalized medicine and ever changing reimbursement models, operating without an EMR seems unfathomable. But where is the study that specifically identifies the benefits and shows improvements from the “To Err is Human” report?

    Even without such explicit data, I’ve personally observed that many clinicians have embraced the EMR and report favorably upon that experience and associated outcomes.

    Healthcare organizations continue to invest time and resources working with their vendors to further enhance the end-user experience with the goal of recognizing more value and benefits from their EMR.  These investments are also targeted at achieving more a consistent adoption of the EMR throughout the clinical community.

    Regardless of my observations, I encourage those in our healthcare industry to share their EMR successes and look to industry representatives to provide updates on the impact the EMR has had on preventable medical errors. 

    Implementing the EMR is just the initial step in addressing the medical shortfalls identified in the report. Ongoing investment and fine-tuning of the EMR supported by positive outcomes will lead to further improvements in care for all of our patients.

    Mike Restuccia is the CIO of Penn Medicine.

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