Articles on this Page
- 12/09/18--19:45: _Victoria’s Bass Coa...
- 12/13/18--11:00: _Dismantling the Hea...
- 12/10/18--19:15: _National group to e...
- 12/11/18--08:11: _Hospital for Specia...
- 12/11/18--09:02: _Updating EHR templa...
- 12/11/18--09:34: _How hospitals can t...
- 12/11/18--11:47: _Many smaller provid...
- 12/13/18--12:22: _Stage 7 EMRAM hospi...
- 12/14/18--11:01: _Blockchain use case...
- 01/25/19--09:00: _Leveraging Modern D...
- 12/14/18--05:05: _EU report looks at ...
- 12/17/18--05:08: _Checklist: 10 steps...
- 12/17/18--05:22: _How one medical gro...
- 12/17/18--05:35: _What to know before...
- 12/19/18--06:27: _How top healthcare ...
- 12/19/18--13:16: _ONC report: Hospita...
- 01/25/19--10:00: _2020 is Fast Approa...
- 12/23/18--19:20: _Digital hospitals i...
- 12/27/18--06:35: _6 Steps to Ensure S...
- 12/27/18--10:27: _Why patients should...
- 12/11/18--09:02: Updating EHR templates to match staff workflows aids ED performance
- Revising the front-end processes to include the intake and triage; re-educating the staff on the emergency severity index five-level triage system;
- Restructuring leadership and clarifying roles to increase accountability for standards of practice and quality of patient care;
- Establishing processes to ensure workflow optimization and capacity issues;
- Redesigning EHR documentation templates to better match processes and staff workflows; and Articulating a shared vision and mission for leadership.
- 12/11/18--11:47: Many smaller providers regretting EHR switches
- 12/13/18--12:22: Stage 7 EMRAM hospital gives insight into China's HIT momentum
- 12/14/18--11:01: Blockchain use case: Electronic health records
- 01/25/19--09:00: Leveraging Modern Data Center Technologies to Boost EHR Performance
- 12/17/18--05:08: Checklist: 10 steps for future-proofing ambulatory EHRs
- 12/17/18--05:22: How one medical group uses EHR to tackle three strategic goals
- 12/17/18--05:35: What to know before purchasing a next-gen ambulatory EHR
- 12/19/18--06:27: How top healthcare executives can use IT to stem the opioid crisis
- Remind clinicians of prescribing guidelines and drug interactions, alert them when they should avoid prescribing opioids, and supply patient education information.
- Automatically calculate the lowest effective dose, based on the patient’s weight, past exposure to opioids, and other factors
- Help clinicians monitor patients’ opioid use on an ongoing basis
- Help clinicians identify and track patients with opioid use disorder
- Support the ability of the clinician to refer a patient with a problem to addiction recovery resources
- Enable health systems and physician practices to analyze opioid prescribing patterns across the organization
- 01/25/19--10:00: 2020 is Fast Approaching – Are your HIT Workflows Ready for Change?
- 12/23/18--19:20: Digital hospitals improve health for Queenslanders: report
- 12/27/18--06:35: 6 Steps to Ensure Secure Connectivity for Medical Devices
- 12/27/18--10:27: Why patients should have full access to their health records
The MasterCare EMR solution will be used by Bass Coast Health clinicians to govern the assessment and management plans of clients, along with the monitoring and measuring of on-going outcomes.
It comprises of a complete EMR and Practice Management solution, with software supporting Minimum Data Set (MDS) collection required for funding, including: Commonwealth Home Support Program (CHSP); Home and Community Care (HACC); Community Health (CH) MDS; Victorian Alcohol and Drug Collection (VADC) and Victorian Integrated Non-Admitted Health (VINAH) data sets.
MasterCare EMR Product Manager Kye Cherian told HITNA that the decision behind using EMR was to have an integrated clinical and administrative system with a collection of reporting data built into administrative and clinical workflows.
“The solution is integrated with a number of other Australian funding and billing types. Many other Victorian services are either using paper-based records and administrative systems with stand-alone applications to collect their reporting data,” he said.
According to Cherian, more Federal and State funded programs becoming available resulted in Bass Coast Health requiring an efficient data collection software solution, in addition to fundamental features in an EMR.
Having initially used PBJ Software Australia technology, Cherian said the move to MasterCare EMR’s intelligent commissioning framework allowed much of the new program data capture and reporting requirements to be supported through software configuration rather than new development.
The three-month implementation involved interfacing MasterCare EMR to the existing DXC iPM Patient Management System, currently used in acute services around Victoria.
“Global Health… brought a deep understanding of Victorian program workflow and data capture requirements. It resulted in a project where both parties took the time to understand the product framework, business needs and data capture requirements,” he said.
“The outcome was a solution that utilises the product’s configurability to support new programs and streamline workflows with minimal software enhancements required.
“A big challenge was migrating five core and high volume programs and their reporting requirements into the new application. With that being said, items such as data migration, integration and change management had to be amplified resulting in the solution having great end-user acceptance and adoption.”
Cherian said the increased efficiency of data collection in MasterCare EMR has resulted in “a wide range of benefits” including ease of reporting and a decreased duplication of work.
“It future-proofs Bass Coast Health on a number of levels. The system has framework to support a number of anticipated program structure changes and being integrated with core e-health foundation services has improved processes.”
Moving forward, Bass Coast Health has planned subsequent phases of the project to enhance the applications’ use as an EMR within the service and to integrate additional features within the application.
Cherian said there is also potential for some planned product improvements to strengthen the product’s support for certain programs and services.
“This will enhance MasterCare EMR’s credentials around the state. Both parties remain committed to working collaboratively in order to become a luminary site for Victorian outpatients and community health organisations.”
Join Michael Catrini, CTO at UConn Health as he outlines the work his organization is doing to achieve its goal of eliminating its data center within 5 years. He will also discuss how UConn Health is addressing data management challenges such as application procurement and endpoint proliferation in light of this strategy. Learn valuable insights, perspectives, and actionable recommendations that will benefit you regardless of what type of provider organization you serve.
A national group is being formed to start work on linking the country’s four regional clinical portals, with approval from the district health boards’ (DHBs) chief information officers.
The group is being led by Stella Ward, chief digital officer at Canterbury DHB.
If successful, the project would allow any clinician involved in a patient’s care to view that person’s computerised health data from anywhere across New Zealand.
Waitemata DHB clinical adviser digital innovations Lara Hopley is a key driver of the project and says clinicians are very keen to be able to see patients’ data from other regions as they often move around the country.
An information paper, Connecting the Regional Clinical Portal to improve patient safety and quality of care, went to the National DHB IS Leadership Forum in November and was noted. The idea was also raised at a recent meeting of clinical IT leads from around the country, who were supportive.
The paper says, “safety and clinical care would be improved if the clinician was aware of the other records, and could seamlessly view, from within their local Clinical Portal, all the available nationally stored computer information about their patient”.
New Zealand’s 20 DHBs are grouped into four regions that each have a shared view of their region’s patient information via Clinical Portal 8 from Orion Health. Of the 20 DHBs, three are not yet using their regional shared portal, but all have imminent plans to move on to one.
The southern region has all five South Island DHBs using Health Connect South and the Midlands region has five DHBs using the e-space Midland Clinical Portal.
The central North Island has five DHBs already using the Regional Health Informatics Programme portal and Capital and Coast DHB has plans to join. Two Northern DHBs are using the Northern Regional Shared Clinical Portal and Auckland and Northland are due to join in 2020.
Hopley says the details of exactly what data will be shared and how to technically achieve the sharing still need to be worked out but she would like it to start as a read-only “portal into other portals”, meaning they would have a tab to access one of the other three portals and land on their dynamic patient summary screen.
“Access to the latest documents is likely to give 80–90 per cent of the information you need while assessing a patient,” she added.
Ultimately, the aim would be to have more integrated sharing of all the data with documents and results from other areas, and the end clinicians not needing to tab into a different portal, she says.
Issues around auditing also need to be agreed, but Hopley says DHBs already have robust internal auditing processes in place and could extend these to monitor staff looking at other portals.
She suggests starting with a proof of concept to prove the value, allowing paediatricians in the Midlands area to access the Northern Regional portal, as a lot of children go up to Starship Hospital for treatment.
“As we are already supplying them with access via CareConnect’s TestSafe portal, we are not really changing what they can see, we are just making it easier,” explains Hopley.
“This would prove the value and allow a blueprint for how we can do this as a minimum viable product, allowing each region to then understand the cost and prioritise accordingly.”
Auckland DHB chief digital officer Shayne Tong says, “in Auckland metro a big number of our population come from outside the region so linking up the portals nationally would be beneficial”.
ADHB recently approved a business case to move on to the Northern Regional Clinical Portal. The project is underway and ADHB has an estimated go-live date of February 2020, followed closely by Northland DHB.
“Our doctors and clinicians move around DHBs so to have that one-stop-shop for the region is pretty incredible and being able to link nationally too is a real benefit,” says Tong.
New York City-based Hospital for Special Surgery, the first specialty hospital to win a HIMSS Davies Award for Excellence. has found a way to use teamwork and health IT to improve processes and care outcomes.
With nearly 19,000 annual inpatient surgeries, requiring close bed utilization monitoring, HSS leadership used to receive operational reports four times a day using manual data collection, but this posed significant operational challenges, and length of stay adherence was also lacking.
To remedy the situation, HSS instituted clinical pathways – procedure-specific, post-op order sets. These pathways established best practices, by coordinating and standardizing care, according to HSS. The pathways are made up of time-based goals and milestones for the interdisciplinary care of defined patient groups, ensuring standardized care across these groups. The pathways also include LOS adherence as part of the performance goals.
WHY IT MATTERS
Many healthcare organizations wrestle with patient volume challenges on a regular basis, requiring close monitoring of bed utilization.
Once HSS began to address bed management and LOS through a multipronged approach that included EHR enhancements and new reporting capabilities – including a capacity management dashboard – capacity improved significantly, hospital officials say.
THE LARGER TREND
There are a variety of care coordination technologies on the health IT marketplace. Vendors include Cipherhealth, eQHealth, GSI Health, Imprivata, Microsoft, Optum and pMD.
We reported last month, for instance, that Penn Medicine used care coordination tech, TrekIT, to reduce LOS and readmissions. According to preliminary findings by TrekIT, the company’s care coordination technology helped Penn Medicine achieve a 50 percent reduction in pneumonia readmissions, a 7 percent reduction in risk-adjusted length of stay, and a 9 percent improvement in HCAHPS scores.
Groups using the technology during clinical rounds were able to access real-time data on their patients 50 percent more often than teams that didn't, while spending 25 percent less time logging into their devices.
Another success story, is Cedar View Rehabilitation and Healthcare Center, a skilled nursing facility in Methuen, Massachusetts, that shifted from piecing together a patient’s encounter history from discharge records and verbal summaries from patients and their families to PatientPing, a technology which provides real-time alerts from hospitals, emergency departments and post-acute care providers every time a patient goes through a transition of care.
The vendor also supplies key clinical data that is valuable for placing a patient’s situation in context, as well as contact information for their healthcare providers. The technology allowed Cedar View to trim LOS for the average Medicare Advantage patient by three to five days.
Diana Manos is a Washington, D.C.-area freelance writer specializing in healthcare, wellness and technology.
Healthcare IT News is a HIMSS Media publication.
The emergency department at St. Mary Medical Center in Apple Valley, California, was operating well over capacity, facing recurring gaps in department leadership, all while facing a systemwide upgrade to its electronic health record system.
Some patients were experiencing prolonged lengths of stay and the department had a high rate of patients leaving the hospital without being seen by a provider. While these issues were not unique to St. Mary Medical Center, the organization wanted to find a way to better serve its patients and support its employees.
It knew that to do so effectively, it would have to engage with external experts, said Marilyn Drone, RN, executive vice president, COO and chief nursing officer at St. Mary Medical Center.
So, in 2015, the medical center reached out to Philips Blue Jay Consulting for their advice on overall emergency department performance improvement – including work with the EHR – and interim leadership.
The 212-bed community hospital asked Philips to provide interim emergency department leadership and lead a process improvement program to reduce left-without-being-seen volume and increase patient throughput capacity.
Philips brought in an interim emergency department manager and an emergency department director who immediately embedded themselves within the medical center's team. These individuals focused on day-to-day operations and staff management and quickly became leaders of the emergency services team.
Next, a performance improvement consultant completed a comprehensive review of key operational metrics, EHR documentation and more, and created a custom performance improvement plan. The consultant worked with the hospital team to update the EHR templates to match staff workflows, minimize workarounds and support increased patient flow.
St. Mary Medical Center also added a third Philips consultant focused exclusively on change management, leading and instructing teams on how to improve key performance indicators. These Philips consultants became part of the hospital team.
There are any number of healthcare consulting firms on the market. They include, for example, Accenture Health Consulting, Bain & Company, The Boston Consulting Group, Deloitte Consulting, Huron Consulting Group, McKinsey & Company and Primaris.
MEETING THE CHALLENGE
"To assess our situation, consultants gathered system and patient data and conducted interviews with our administrators, departmental leaders and staff, covering topics such as intake, triage, processes and education," Drone explained. "They also spent considerable time observing patient workflow, departmental processes and communications."
Consultants then conducted a performance assessment including a thorough analysis of data collected on volume, arrival patterns, staffing patterns, emergency severity index level distribution, department billing, disposition breakdown and length of stay – some of the key performance metrics the hospital wanted to focus on.
"The consultants worked with our nurses and clinical staff who were closely aligned with our IT team to develop and implement a daily dashboard," Drone said. "The dashboard populated the necessary data and provided a snapshot of the emergency department operational performance. A daily PDF report was created to enable the team to quickly see what was working well and where further changes may be necessary."
After the assessment, hospital staff and consultants agreed on several opportunities for improvement, including:
"Following the assessment, we assembled a performance improvement work team," Drone said. "Led by Philips, this group consisted of hospital physicians, administrative leaders and emergency department ancillary staff. The objective was to create an action plan focused on decreasing the walkout rate as well as the length of stay of the department."
The work team completed a deep-dive review into each area identified in the assessment and leveraged the data analysis and stakeholder input gathered earlier, she added. They developed recommendations for process change, with priority given to the change initiatives that could make the greatest impact, she explained.
St. Mary Medical Center, with the help of the consultants, was able to reduce emergency department discharge patient length of stay by 34.4 percent, reduce the left-without-being-seen rate by 85.3 percent, and reduce the arrival-to-provider time by 66.2 percent.
"Implemented changes included front-end processes, emergency severity index five-level triage training, improved patient communication, and other process standards," Drone said. "As a result, we were able to reduce left without being seen from 7.5 percent to 1.1 percent and emergency department discharge length of stay from 361 minutes to 237 minutes."
A critical driver of the hard results was the development of a "Middle-Trac" process, Drone said.
"Derivative of a split-flow process where patients are triaged quickly into parallel care streams, Middle-Trac focuses on patients in the middle, emergency severity index Level 3 – those who do not require immediate lifesaving treatment," she explained. "The Middle-Trac patient flow keeps these patients vertical and moving through the department while not occupying valuable treatment spaces until a disposition decision is made."
Like an assembly-line, the Middle-Trac process works cohesively occupying 14 treatment spaces, she added. When a patient arrives at the emergency department, a triage nurse classifies the patient into one of three categories: immediate bed needed; fast track appropriate; and remaining Middle-Trac patient population, she said. A carefully detailed process flow maximizes continuity of care, manages essential resources, and minimizes provider hand-offs, she said.
ADVICE FOR OTHERS
"For me, the most important thing to consider is how will these consultants work with our key stakeholders?" Drone advised. "Do they have the real-world, clinical experience this role and engagement demands? Can they relate to the challenges we are facing? Do they have a strong track record of success?"
Just like hiring any other team member, hospital staff interviewed each consultant before they joined the project; it was vital to ensure they had the high level of expertise the hospital needed and would be a good fit with the rest of the team, she concluded.
Some U.S. hospitals and health systems have turned their successful in-house work in health IT into commercial offerings that other hospitals and health systems can benefit from. This work is typically done in what is called an innovation lab.
This is not necessarily an easy task. First one must have the talent to come up with great IT. Then the IT must be proven. Then the IT must be packaged as a product. And then the package must be commercialized and marketed to turn the healthcare organization’s IT operations into a profit center.
Some healthcare organizations have been very successful in these efforts. Two include: Sinai AppLab at the Icahn School of Medicine at Mount Sinai Health System in New York; and UPMC Enterprises, the commercialization and innovation arm of UPMC in Pittsburgh, Pennsylvania. Executives at these two organizations offer advice to C-suite executives at healthcare provider organizations considering commercializing in-house health IT.
Right from the start
Provider organizations have to set up teams and technology efforts in ways that will make them most successful at making sure that in addition to producing excellent technology they also are keeping successful commercialization in mind.
“Innovation centers in healthcare can try to implement various technologies or can focus on one set of problems in particular,” said Dr. Ashish Atreja, associate professor and chief innovation officer, medicine, at Sinai AppLab. “Our AppLab digital medicine innovation center has been focused the last five years on building and integrating digital medicine technologies for value-based healthcare.”
This has allowed Sinai AppLab to see the technologies from a unique lens, prioritize them, and align them with business value over a period of time, he said. ROI for the innovation center is generated through one of the following three ways, he explained.
First, scalable implementation in the health system – decreasing revenue leaks and penalties, and increasing revenue through better access and value-based incentives. For example, Sinai AppLab implemented a pre-post patient empowerment platform for patients in joint replacement bundles to optimize them before surgery (pre-rehab), decrease 7-day and 30-day readmissions, and increase their functional outcomes. The health system directly reaps the benefit from this technology as soon as it is implemented – no delays related to licensing and testing or approving new technologies, Atreja said.
Second, licensing of different technologies and intellectual property.
“We have worked closely with Mount Sinai Innovation Partner to identify and license technologies from Medical School and Health Systems, especially around digital medicine – apps, analytics, remote monitoring, etc.,” Atreja said. “Licensing models in health IT are very different than devices or drugs and my previous experience in licensing virtual paging technology from Cleveland Clinic has helped us capitalize this revenue stream.”
And third, creating spin-off entities. While spin-offs are very lucrative, the technology has to be addressing a real problem, very novel in its approach and mature for scalability, before it can stand on its own legs in a startup, he stated.
“We spent over three years iterative building and testing a digital medicine platform, RxUniverse, that curates best evidence-based apps and solutions, prescribes them at the point of care to individual patients’ smartphone or to populations at large as customizable links, and collates data back from multiple sources to dashboards linked to EHRs,” he explained.
The problem Sinai AppLab tried to solve was that neither patients nor providers have time or resources to identify which solutions are evidence-based out of more than 350,000 apps available.
"Innovation done half right cannot support scalable transformation."
Dr. Ashish Atreja, Sinai AppLab
“We saw only 7 percent adoption if patients were just informed about an app since they often forget the exact name, misspell the name, or get lost among many apps with the same name or lost their unique code,” he said. “By enabling a digital prescription which comes as a text link on their phone, we have seen adoption increasing to 92 percent.”
Tal Heppenstall, president of UPMC Enterprises, said the focus on commercialization needs to be part of the mission of any such innovation center from the very start if one wants to create technologies and solutions that can make a difference in healthcare at scale.
“While some of our ideas and products are ultimately used only to improve operations at UPMC, which is still a win, we always start with the broader market in mind and measure the success of UPMC Enterprises on that basis,” he said. “It’s important to quickly get at least one other customer besides your own health system to validate your assumptions about the market and the technology.”
Click on page 2 below for a commercialization deep dive, and much more
Commercialization deep dive
Atreja and Heppenstall take a deeper dive into commercialization by looking at one of their products and walking through the factors that had to be handled in successfully commercializing the health IT.
“One of the technologies that we have successfully commercialized is a telemedicine solution for long-term care facilities, built around research led by a UPMC geriatrician,” Heppenstall said. “The goal is to make geriatricians available virtually on nights and weekends to potentially avoid unnecessary transfers and hospitalizations of nursing home residents. Curavi Health, as the company is called, now offers its services in about 50 facilities in three states.”
Curavi Health’s technology was developed specifically for nursing homes and the workflow of their staff. A critical factor in launching Curavi – and other companies in the UPMC portfolio – is having UPMC as an initial customer, so UPMC clinicians and staff can provide rapid feedback for further development and improvement, he explained.
“Many startups die in the pilot stage, so we think that having a customer/investor/partner like UPMC is critical to improving those odds for healthcare innovators,” he said. “It’s also important to show immediate value and return on investment given today’s healthcare cost pressures.”
Atreja of Sinai AppLab has an excellent vantage point for commercialization.
“Speaking from the experience of licensing one of the first virtual messaging applications from Cleveland Clinic and creating spin-off Rx.Health from Mount Sinai, I can say that commercialization first starts with identifying real need that people are willing to buy/invest in,” he said. “Once the solution is conceptualized or started to be made, we first fill an invention disclosure form, an IDF, typically to tech transfer offices.”
Unproven business models
It’s key to note that for new technologies with unproven business models, none of the paths – licensing, spin-offs, etc. – are clear from the outset, he added. So it’s prudent not to get carried away and invest too much money in intellectual property protection or creating a startup too early, when technology does not have legs, he said.
“The journey of startup evolves in quite unpredictable fashion,” he said. “For example, Rx.Health has now expanded the platform to prescribe patient-reported outcomes, surveys, digital care plans for pre-post surgeries, shared decision making tools before complex decision making, appointment reminders, campaigns to close the care gaps, as well as transitions of care support to reduce readmissions.”
Identifying different business models, negotiating terms for licensing/spin-off and finding key co-founders for spin-off are some of biggest challenges that prevent many good technologies making it to the market, he added.
So ultimately, what do the CEO, CFO and COO at the umbrella healthcare organization need to know about commercialization efforts? How does a CIO inform them on efforts? What must they understand to help commercialization efforts be successful?
Transformative innovation starts with the CEO, Atreja said.
"It’s important to quickly get at least one other customer besides your own health system to validate your assumptions about the market and the technology."
Tal Heppenstall, UPMC Enterprises
“Having executive sponsorship from the C-suite – it varies between the CEO, CFO, COO, CIO, CMIO and CMO – and keeping them informed about possibilities, barriers and success stories is key to continue momentum and make innovation centers sustainable,” he said. “Successful commercialization efforts take more than a few years and we are seeing a trend where innovation centers are supported by the operating budgets of health systems, rather than a 1-2 year grant or philanthropy to ensure longevity of innovation initiatives.”
Once there is a success story, it’s good to have it shared by the C-suite to the board and to the public through press releases, social media, and articles or publications, he added.
Treating an effort like a vendor
The C-suite needs to understand that most of these efforts will fail and that the ones that succeed will eventually need to be treated like a vendor and not a department of the health system if they are going to grow and attract the best talent, Heppenstall said. He and his team regularly update their board on the activities of UPMC Enterprises and have a well-defined process for authorizing investments.
Atreja and Heppenstall have advice for peer healthcare provider organizations considering getting into the innovation lab and commercialization business.
“Be sure you are ready to accept the risk of failure because that’s a given for innovators,” Heppenstall said. “And be sure that you have the patience, board support and clinical buy-in that will be necessary to succeed.”
Let strategy guide the innovation, rather than vice versa, Atreja advised.
“Once a strategic roadmap is defined, it’s crucial to bring on the right team, with the right support for many years and the right reporting structure to the board or C-suite so these centers/labs have the maximum chance to thrive and change the culture of the institution,” he said. “Innovation done half right cannot support scalable transformation.”
Focus on The Business of Healthcare
In December, we take a deep dive into what top business decision makers need to know about digital transformation.
Findings from a recent Black Book survey shouldn't be much of a surprise to anyone in the healthcare IT world: changing electronic vendors is expensive, time-consuming and full of hidden challenges.
Bigger health systems usually weather the disruption more easily and come out happier on the other end. Smaller providers, however, struggle to cope with hidden costs, user frustration, and longer than expected downtime, among other things.
Brand-name recognition and overeager sales pitches hid some of the most significant challenges providers encountered. Black Book found that 71 percent of providers who switched EHRs saw a drop in interoperability.
WHY IT MATTERS
EHRs are expensive, and also mandatory. When they don't work well or when physician buy-in to the system is lackluster, it eats into revenue which can already be strained to recoup on the cost of an EHR implementation.
Cost overruns or implementation delays caused temporary or permanent layoffs for 22 percent of those responding in the survey, not to mention additional headaches for the remaining staff and lost more money for the system.
Finally, clinician burnout, an already worrisome trend, can be exacerbated by changing EHR systems, something an astounding 98 percent of respondents said wasn't a part of the conversation as they switched EHR systems.
"No other industry spends so much, per unit of IT, on the part of the business that is shrinking the fastest and holds little growth as hospital inpatient revenues," said Doug Brown, president of Black Book.
THE LARGER TREND
Black Book finds the majority of financially threatened healthcare systems regret switching EHRs – so changing horses mid-race might not be the first move a smaller or struggling provider might want to make. The survey notes that changing providers is a risk that many small healthcare systems are unable to make work to their benefit in the long run.
Instead, taking steps such as recognizing the impact of physician burnout, or directing more focus on achievable financial goals such as interoperability or greater functionality may be a smarter tactic.
ON THE RECORD
"In retrospect, mid-market system CIOs spent a lot of money focusing on functionality and incentive-dollar achievement, thus many did not appropriately approach long-term value by dealing with basic issues, such as departmental workflows, usability, interoperability and data-sharing standards," said Brown.
"We found the majority (69 percent) of struggling hospital systems in 2018 that are dealing with very tight margins – or even losing money – regret their IT choices, which still have them teetering between being able to stay open or having to close," he said.
Benjamin Harris is a Maine-based freelance writer and and former new media producer for HIMSS Media.
Blockchain "is not meant to wipe out existing legacy systems," said Maria Palombini, director of communities and initiatives development at the IEEE Standards Association. In most cases, the idea is for the network approach to supplement IT applications and innovate the ways they manage data.
That's what Massachusetts General Hospital is hoping, for instance, with the partnership announced this past month with MediBloc, a Korean blockchain startup. The aim is to pilot new DLT-based storage and exchange mechanisms that complement, rather than supplant, its existing electronic health record.
The hospital plans to "explore potentials of blockchain technology to provide secure solutions for health information exchange," said Synho Do, director of MGH's Laboratory of Medical Imaging and Computation.
One of those means of exchange could be via the patient, as Palombini described in our story. (You can also listen to our recent webinar with her here.)
"When you think about all the data (in and EHR), what do you put in it? Genomic data, hospital records, immunization records, lab results – there's an enormous amount of data," she said. "The question then becomes, ‘Do I have to do this over and over every time I go to the hospital or I go to my doctor?'"
We could soon see a world where "everything you have in your health record gets put into the blockchain, and then the patient is managing their health record," she said. "I have my health record, and then I go to my doctor I give him a token to access my records."
In a lot of ways, EHRs represent an ideal application for distributed network tech such as blockchain. As Drexell Neumann a Weill Cornell Medical College medical student explains, it may even be a "panacea" to some of their longest-standing challenges: interoperability and security.
"Blockchain’s open access would enable changes to an individual’s EHR (new imaging, procedures, labs) to be updated in real time on an EHR blockchain and instantly available to parties involved in an individual’s care (health care providers, pharmacies, insurance companies, the patient)," he said. "No more issues with compatibility of different EHR systems or waiting for faxes."
Moreover, "using a decentralized ledger in EHRs also means data cannot be held ransom," he added. "Each user has an updated copy of the blockchain, thus hackers cannot obtain control over the ledger and hold it ransom as WannaCry did to many providers in 2017."
Writing for the Harvard Business Review, longtime Beth Israel Deaconess Medical Center CIO and blockchain enthusiast Dr. John Halamka, says the technology could help address the "vexing problem" facing health systems everywhere: "how to share more medical data with more stakeholders for more purposes, all while ensuring data integrity and protecting patient privacy."
It has to do with blockchain's structure – enabling a new paradigm for dat a exchange, he said.
"Traditionally, the interoperability of medical data among institutions has followed three models: push, pull, and view," Halamka said, "each of which has its strengths and weaknesses. Blockchain offers a fourth model, which has the potential to enable secure lifetime medical record sharing across providers."
The potential for blockchain to revolutionize data exchange along these lines is described in detail in a 2016 case study coauthored by Halamka and BIDMC colleagues with MIT Media Lab.
"Imagine that every EHR sent updates about medications, problems, and allergy lists to an open-source, community-wide trusted ledger, so additions and subtractions to the medical record were well understood and auditable across organizations," said Halamka.
"Instead of just displaying data from a single database," he explained, "the EHR could display data from every database referenced in the ledger. The end result would be perfectly reconciled community-wide information about you, with guaranteed integrity from the point of data generation to the point of use, without manual human intervention."
This and similar approaches are already at work, with startups such as London-based Medicalchain, which develops distributed ledger technology to store patient health records as "a single version of the truth" able to be accessed with appropriate permission by physicians, hospitals, labs and insurers.
In a post on Medium, the company highlights the benefits of such an approach: "Data can only be accessed by the patient’s private key; even if the database is hacked, the patient’s data will be unreadable (it’s all encrypted); patients have full control over accessing their healthcare data; patients will control who sees their data and what they see; instantaneous transfer of medical data, where every member of the distributed network of the health care blockchain would have the same data for the patient; there’s a reduced risk of errors, and better patient care."
Medicalchain already has high-profile partners such as the NHS and Mayo Clinic, which announced its plans to work with the company on several EHR use cases earlier this year.
In a recent interview with HIMSS Europe, Dr. William Gordon of Harvard Medical School said that while much of the excited discussion around blockchain is "still hype, particularly when it comes to clinical data," the technology "is promising for EHR data in a few ways."
That said, big challenges remain, said Gordon.
"First is the sheer volume of clinical data," he explained. "Blockchains as they exist today are not designed for storing large amounts of data, such as would be generated during a clinical encounter."
Second, he said, "blockchain relies on some form of a unique identifier to link records across individuals, which means identity will have to be managed somewhere to de-duplicate patient IDs."
And third, Gordon explained, "identity on blockchain tends to be anonymous but not private. What this means is that while transactions are anonymous (real identity is hidden), they are publicly recorded. Once an individual’s identity is linked to a blockchain identifier, their entire history of transactions is available – which could be catastrophic for clinical data. There are mechanisms to mitigate these issues – for example, 'private' blockchains that aren’t public, or storing data 'off-chain' – these issues need to be addressed more fully before we see widespread EHR data sharing via blockchain."
Still, he said, "the challenges around blockchain are surmountable, and there is a tremendous energy around finding the right use cases in healthcare. Additionally, the underlying technology is changing rapidly, with protocols suited to different verticals being developed."
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The number of people seeking health information online across EU countries nearly doubled last year, compared to figures from 2008, according to research cited in a new report from the European Commission and the Organisation for Economic Co-operation and Development (OECD).
The Health at a Glance: Europe analysis, published in November, looks at the state of health of EU citizens and the performance of health systems in the 28 EU member states, along with five candidate countries and three from the European Free Trade Association.
Figures from an annual European Information and Communication Technologies survey mentioned in the report, including the responses from around 150,000 households and 200,000 individuals aged between 16-74, found that half of all EU residents sought health information online in 2017, with the number going up to around 70 per cent in the Netherlands and Finland.
But the 2016 version of the survey found that only 13 per cent of EU residents made a medical appointment online, although the number went up by five per cent compared to figures from 2012. Looking at individual countries, nearly half of all Danish residents reportedly made an appointment with a health care practitioner online in 2016.
Use of EHRs and ePrescribing
The Commission and the OECD’s new report also shows that the use of electronic health records has been increasing across the EU. A 2016 survey of OECD countries, which included 15 EU member states, revealed that all or nearly all primary care practices in Estonia, Finland, Greece and the UK had implemented such a system. The situation was different in Poland and Croatia, however, where it was reported to be “much more limited”.
Meanwhile, a 2018 survey from the Pharmaceutical Group of the EU found variation in the implementation of ePrescribing systems across EU countries. Although 90 per cent of prescriptions were transmitted to community pharmacies electronically in Denmark or Sweden, figures indicated that ePrescribing had not yet been implemented in Bulgaria, Malta or Poland. According to the Commission, these countries expressed an intention to implement ePrescribing at either regional or national levels during the coming years.
“Digital technology offers great opportunities to deliver health services more efficiently, and the European Commission supports a digital transformation of health systems to empower citizens to have access to their health data and to promote exchange of health data among health care providers across the EU,” the report reads.
"Every European citizen should have an electronic health record"
In a mid-term review on the implementation of the digital single market strategy, the Commission said it would take further action in three areas: ensuring citizens’ secure access to and sharing of health data beyond borders, connecting data to drive advancements in “research, disease prevention and personalised health care”, and empowering citizens to take control of their care through digital tools.
Until 20 December, the EU institution is accepting feedback on an initiative to create a recommendation for the establishment of a European EHR exchange format.
"Every European citizen should have an electronic health record - and this record should be easily exchangeable across Europe. We will soon publish a recommendation on how this should happen,” Roberto Viola, Director General of DG Connect, European Commission, recently said at the EU Health Summit.
Source: Health at a Glance: Europe report, published in November 2018.
Following are insightful tips from ambulatory EHR experts on how best to prepare today for the ambulatory EHR technology of tomorrow.
1. Healthcare organizations need to mitigate physician frustration and simplify the EHR.“For many years, the focus in EHR development was on meeting regulatory requirements, which meant users had to adapt to less-than-optimal solutions,” said Allscripts CEO Paul Black. “That comes at a cost: When provider wellness suffers, it can negatively affect decision making and patient safety.” User-centered design principles must be employed to create more intuitive systems, overcome workflow challenges and make EHRs smarter to give users the right information at the right time, he said.
2. Providers must prepare for the growth in Millennials. That’s because they’re digital natives willing to harness tech tools to play a greater role in their health and bringing new expectations to the system. “Consumers are viewing health solutions in terms of overall wellness, patient experience and outcomes, an indication that patient-centric solutions will become the norm for all aspects of healthcare,” Black said. Many pediatric practices are discovering that Millennials have different expectations for their children’s healthcare than previous generations, so services such as online scheduling and e-mail appointment reminders have become an expectation for the generation that grew up with the internet, he added.
3. Start leveraging mobile to boost physician productivity.“While most EHR vendors offer mobile versions of their applications, many practices aren’t utilizing mobile in the right way,” said Richard Atkin, CEO of Greenway Health. “When utilizing mobile applications, make sure the offerings create a seamless user experience and are implemented appropriately into your workflow to maximize results.”
[Also: What to know before purchasing a next-gen ambulatory EHR and here's a case study about how one medical group uses its EHR to tackle three big goals]
4. Rethink the physician/patient encounter. It will only continue to change in the years to come. “What does your organization provide that others do not?” Atkin pointed out. “Today, patients want actions, not just conversations. Ensure your organization is truly committed to patient care by providing patients with specific, alternate health regimes and walking them through the costs of visits, medications, etc., so they have a better understanding of their overall care plan and how much each plan may cost.”
5. Evaluate or migrate to cloud-based applications and platforms.“They offer scalability, AI and security investments beyond the reach of most organizations,” said Robert Van Tuyl, CIO of Easter Seals of the Bay Area, which uses athenahealth’s ambulatory EHR.
"Cloud applications offer scalability, AI and security investments beyond the reach of most organizations."
Robert Van Tuyl, Easter Seals of the Bay Area
6. Apply design thinking concepts. This goes to both EHR makers and customers because to product development can help solve problems that address end-to-end use-cases, improve ease-of-use for clinicians and improve adoption rates, Van Tuyl said.
7. Integrate population health system tools to leverage evidence-based care. These enable clinicians to collaborate with care teams and patients, said Girish Navani, CEO and co-founder of eClinicalWorks. By investing in the system, providers will have a more comprehensive approach to healthcare by further understanding their patient populations, he added.
8. Embrace machine learning and artificial intelligence.“AI and machine learning are going to play an important role in the future of healthcare by establishing intelligences that create inferences to improve care outcomes,” Navani said. “Quantitative data will be profound with direct integration into the EHR to help doctors at the point of care.”
9. Yes, the same goes for genetics and genomics. By many accounts genetic screening will become cost-effective and, in turn, commonplace in short order. “Genetic screening will be monumental to help practices understand disease patterns, better assess risk, and promote better medical outcomes,” Navani said. “Integrated directly into an EHR, any order, such as a medication written by a physician, will be validated against a patient’s genetic profile.”
10. Craft a living care plan. Betty Evans, CEO of group practice Oak Street Medical, which uses the EHR from Greenway Health, recommends that practices and medical groups build a “living care plan” into their EHRs that is both user-friendly and integrated into a patient’s record. Include “the ability to create flags and generate reports for tracking as needed,” she said.
Focus on The Business of Healthcare
In December, we take a deep dive into what top business decision makers need to know about digital transformation.
Prime Care Family Practice in Prince George, Virginia, is using its ambulatory EHR to help deliver optimal care while gaining efficiencies and trimming costs. The EHR is part of the backbone of operations at the physician group practice.
“Documentation consistency is critical to standardizing care,” said Dr. Amar Shah, COO and a practicing physician. “The creation of templates for chronic disease states and standing orders ensures a high level of quality. Making these tasks efficient and reproducible saves times, which can be directed toward patient care.”
Integration with lab interfaces and hospital networks no longer is an option, he said. Primary care providers are tasked with coordinating care efficiently within a 20-30 minute office visit. Phone calls and fax requests for patient records increase delays in patient care.
A well-populated EHR
“Providers and patients now demand this information be directly populated or searchable from the EHR,” he said, speaking of his ambulatory EHR from eClinicalWorks. “Patient engagement is of paramount importance. The ability to communicate to patients via the patient portal about appointment reminders, gaps in care and chronic care management enhances a practice’s outreach.”
One workflow Prime Care Family Practice has implemented for its providers is chart prep at the front desk registration with certified medical assistants. The group practice realized that accurate demographic and insurance information improved its ability to collect fees. Additionally, at check-in, every patient is asked to provide an e-mail and is signed on to the patient portal app.
[Also: What to know before purchasing a next-gen ambulatory EHR and here's a checklist: 10 steps for future-proofing your ambulatory EHR investment]
Next, the medical assistants are trained to reconcile medications; perform depression, alcohol and smoking screening questionnaires; and update/provide preventative health items, such as order mammograms/colonoscopy or give a flu or pneumonia vaccine using standing orders. So, by the time the physician sees the patient, 50 percent of care has already been performed. The patient is then ready for the physician.
"All providers use preformed templates for most chronic and acute disease states to be sure all aspects of care are addressed."
Dr. Amar Shah, Prime Care Family Practice
“All providers use preformed templates for most chronic and acute disease states to be sure all aspects of care are addressed,” Shah said. “This ensures consistent high-level quality of care and efficient and accurate documentation. During the checkout process, the patient is then reminded by the medical assistant and the registration staff to login to the patient portal for access to their health records to review results, refills, questions and appointment requests.”
Ultimately, this workflow process has limited provider burnout, improved patient engagement and standardized care across all disease states, thus improving quality, Shah reported. And the team approach has empowered the entire office to be intimately involved in the care of every of patient, he added.
Three strategic goals
Further, a strategic goal for the provider organization has been to focus on quality, cost and overutilization.
“Our EHR can provide analytics, which has been a stepping stone for our providers to be a part of a High Value Practice,” Shah said. “Giving visibility to providers about their attributed patient population has made the greatest impact on improving quality, and reducing cost.”
In the past, the practice relied on payers to provider this data, which was usually 90 days or older. The practice needed real-time analytics to make actionable changes for gaps in care, which led the practice to the eClinicalWorks HEDIS dashboard.
“We noted our influenza vaccination rate was under the national average,” Shah said. “As a result, we implemented an influenza campaign in our office by having every employee ask the patient for a flu shot and we then created a standing order for nurses to provide the vaccine. This resulted in a 25 percent increase in influenza vaccination the first year and a 35 percent increase in influenza vaccination the second year.”
Future focus areas
Looking ahead, group practices would be smart to focus on three general areas: transformation, analytics and office culture, Shah advised.
“Practices must embrace transformation and continually implement workflows that make care more efficient and standard,” he said. “Implementation of open access/online scheduling to the creation of positions for quality gap closure, transition of care and chronic management are a few examples.”
Giving visibility to providers about the health of their patient population can ultimately change behavior, transitioning focus toward value-added practices to improve quality and reduce cost, he said. And lastly, he added, empowering the entire office staff to take part in every patient’s healthcare makes it a true medical home.
Focus on The Business of Healthcare
In December, we take a deep dive into what top business decision makers need to know about digital transformation.
Electronic health record systems are the backbone of ambulatory practices today and need to be designed and tailored to meet the specific needs of physicians. Ambulatory EHRs are tasked with streamlining workflows, improving care and helping to trim costs. And like every technology, ambulatory EHRs are evolving, changing in different ways to meet the constantly transforming healthcare marketplace.
It’s up to physician group practices, health systems that own numerous group practices, and other ambulatory healthcare organizations to stay abreast of change to make sure they are getting the most out of their EHRs, and to make sure that they don’t fall behind technologically in a highly competitive industry.
Ambulatory EHR experts at both provider and vendor organizations have a wide variety of informed opinions and helpful insights as to where the technology is headed next so that ambulatory healthcare provider organizations can best prepare for where they need to be in the years ahead. And they share their expertise here, as well as in a checklist of both evolutionary changes coming soon and ways organizations can future-proof in advance of such changes and in a case study of an ambulatory EHR in action.
But to understand where ambulatory EHRs are headed, it’s important to first understand where things stand today. EHR experts have lists of components that they believe make up a high-quality ambulatory EHR now.
Among ambulatory provider organizations in the top 5 percent that have attested for meaningful use, Epic, Allscripts and athenahealth are the top EHRs for solo practitioners and for group practices with 2 to 25 physicians, according to research from HIMSS Analytics. Epic, Allscripts and Cerner come out on top for group practices with 26 or more physicians.
[Case study:How one medical group uses its EHR to tackle three big goalsand here's a checklist:10 steps for future-proofing your ambulatory EHR investment]
An ambulatory EHR should have the power to connect communities, providing clinicians immediate analysis and insights to initiate meaningful change, said Allscripts CEO Paul Black.
“Think of it as a practice’s backbone technology that significantly and positively impacts patient care delivery and outcomes,” Black said. “To achieve these results, it is critical for the EHR to have the capability to customize workflows, and coordinate and deliver primary and specialized care.”
Clinicians want to take great care of patients while staying independent and financially viable. They do not need complicated systems that create as many headaches as they solve.
“Clinical and financial functionality is important,” Black said. “Fundamental components such as e-prescribing, mobile access and robust, flexible clinical features will help practices deliver quality patient care, combined with powerful financial and administrative support.”
A comprehensive chart is critical to an ambulatory EHR, one that provides enough information to optimize clinical decision making and care planning and prevents the need to repeat tests or the risk of potentially doing harm, for example, administering a medication for which the patient has a severe allergy.
“EHRs need to employ effective clinical documentation tools that allow clinicians to capture patients’ current condition/disease states, both delivered and planned care, and satisfy regulatory requirements seamlessly,” said athenahealth Director of Ambulatory Services Jasmine Gee. “This frees up clinicians to do less administrative work and spend quality time with more patients.”
Another must-have for ambulatory EHRs is computerized physician order entry – effective CPOE tools enable easy order entry (for instance, labs, imaging, referrals, etc.) and present information to physicians that drives more effective ordering decisions, Gee added.
“And EHRs must be offering, embracing and actively improving interoperability,” she said. “The ability for the clinician to construct a 360-degree view of a patient’s clinical information, regardless of where care has been delivered, is only possible if the EHR proactively searches for and consolidates information across both traditional and non-traditional data repositories.”
"Today’s EHR must offer doctors methods to connect with patients outside of the walls of the office to help them stay healthy."
Girish Navani, eClinicalWorks
And fundamental to any ambulatory EHR are tools that help providers better understand each patient’s needs, more accurately gauge risk, and promote more effective treatment and improved outcomes, said Girish Navani, CEO and co-founder of eClinicalWorks.
“Specifically, tools for interoperability to improve outcomes and the transmission of data, population health to analyze critical health information, and patient engagement services to virtually connect the patient and providers,” Navani said. “These tools are crucial to establishing expanded intelligence and creating inferences that improve care outcomes.”
State of the art
Ambulatory EHRs today are marked by a variety of top features and functions, the state of the art from which the technology will grow into the future.
“Capabilities enabled by technology are emerging with most EHRs able to provide some level of access to patients and providers to participate and collaborate during the care cycle,” said Robert Van Tuyl, CIO of Easter Seals of the Bay Area, which uses athenahealth’s ambulatory EHR. “Patient portals for access to at least a subset of their electronic medical record, scheduling appointments, and participation at a beginning level of remote care, is possible today.”
On another note, standards like FHIR are emerging for the exchange of electronic medical records between providers, but a lack of adoption and/or willingness to share this data efficiently and effectively with outpatient healthcare providers still is creating challenges to implementing fully integrated care.
Elsewhere, today’s EHRs should offer not just methods and tools to make a doctor’s office more efficient, but ways for doctors to connect with patients more meaningfully, said Navani of eClinicalWorks.
“Providers are moving from the traditional fee-for-service to more of a value-based care, forcing EHRs to cater to the evolving needs and changes with modules to better manage quality programs,” he said. “Today’s EHR must offer doctors methods to connect with patients outside of the walls of the office to help them stay healthy. The connection will allow providers to be successful at the different quality programs they participate in, such as reminder services, portals, and other patient engagement tools that are directly integrated into the EHR.”
How doctor’s work
Today’s ambulatory EHRs should work the way physicians work, said Richard Atkin, CEO of health IT vendor Greenway Health. If EHRs give physicians time back and improve their quality of life, they can focus on providing the best quality care to patients; EHRs today should provide added value to ambulatory practices and serve as a one-stop-shop system, Atkin added.
“The collective data recorded in the EHR should be in a discrete format and suggest preventative steps that can be taken – additional office visits, exams, tests – to give the patient the best chance of achieving the highest quality of care,” he said. “While business intelligence and automation features like this are common in other industries, they’re only now becoming mainstream in healthcare.”
In addition, EHRs that support patient portals and messaging systems are a must-have today in the age of healthcare consumerism, he added.
Allscripts CEO Paul Black said the state of the art in ambulatory EHRs today includes four components: mobility, the cloud, comprehensiveness and data sharing.
“Mobility gives you what you need, when and where you need it,” he said. “The cloud reduces total cost of ownership while improving scalability and security. A comprehensive solution integrates practice management and patient engagement. And data sharing delivers a single, shared patient record.”
The future of ambulatory EHRs
So where are ambulatory EHRs evolving toward? What will be the features and functions of tomorrow that group practice physicians can’t live without? Ambulatory EHR experts point in many directions, from artificial intelligence to genomics and more.
“Ambulatory service providers are in the unique position to provide comprehensive integrated care management and care coordination across a spectrum of services,” said Van Tuyl of Easter Seals of the Bay Area. “The ability for cloud-based ambulatory EHRs to ingest data from multiple data sources including medical devices and consumer health activity devices and provide a longitudinal view of services provided and care-team interactions will be key to integrating more advanced technologies like artificial intelligence and machine learning to reach better outcomes and efficiencies across the healthcare system.”
Patient engagement through mobile apps for managing health and wellness could be the driving force to making personal medical records a reality with which EHRs will need to exchange data, he added. Consumer-facing apps like Apple Health Records could provide availability of near-real-time data from a variety of trusted devices to augment and enrich medical records that reside within traditional electronic medical records, he said.
"It is critical for the EHR to have the capability to customize workflows, and coordinate and deliver primary and specialized care."
Allscripts CEO Paul Black
In the future, EHRs will not just track a patient’s adherence to his or her care plan but also alert providers when a patient is missing certain elements or when specific steps of the plan have not been completed, said Atkin of Greenway Health. Machine learning will be more commonplace in EHRs, guiding the provider and suggesting medications or care plans based on additional patient data and information stored in the system, he added.
“Genomics will also unlock new possibilities for personalization and wellness in healthcare, allowing provider organizations to design transformational experiences for patients,” Atkin said. “Additionally, behavioral health and socioeconomic factors will become important elements. For example, a patient may not be coming to doctor appointments as recommended because he or she lives in an underprivileged area without transportation. This ultimately tells providers that overall community changes need to be made in order for patient outcomes to improve.”
Offering different choices
Looking ahead, EHRs will also be capable of evaluating the financial implications of clinical decisions and giving a set of different choices – such as various treatment options and drug prices – to improve the patient experience, meet their rising expectations and reduce costs even more, Atkin said.
And next-generation EHRs should be more advanced in the way they receive information, leveraging voice recognition to cut down the administrative process of entering data even more, he added. This will have even bigger benefits as providers work to spend more time with patients and less on documentation, he said.
Artificial intelligence will be a critical element in the evolution of ambulatory EHRs. Incorporating machine learning capabilities to learn physician treatment patterns, for example.
“It can pre-populate information based on these patterns and deliver preference reminders,” said Allscripts’ Black. “It’s constantly surveilling trends by user, organization and region to create opportunities for more efficiency. Plus, the power of artificial intelligence surfaces information relevant to the encounter in real time, which helps improve quality and immediate interaction with the patient.”
Ultimately, this reduces the amount of time spent on documentation, helping address the problems of EHR fatigue and physician burnout, he added.
In addition, more and more vendors will have open IT systems. Open architecture makes it easy to create apps, share data and upgrade individual components of a platform.
“When we add true vendor-agnostic interoperability, we enable providers to seamlessly communicate and exchange data with any trusted system and use that data to make better informed decisions at the point of care and beyond,” Black said.
On the horizon, EHR makers will incorporate EHR-agnostic precision medicine and genomic capabilities within their workflow, Black said.
“These types of capabilities,” he added, “should capture and store genomic data from a range of sources, harmonize clinical knowledge and genomic research to identify relevant information, and then push the resulting insights to the point of care to better determine the most effective regimen for the patient.”
Focus on The Business of Healthcare
The sheer scope of America’s opioid crisis—more than 40,000 opioid overdose deaths just in 2017, and more than 2 million addicted—almost defies comprehension. Many of us know one or more of the people that those horrifying numbers represent. We all want to help.
While fewer than half of those deaths were due directly to prescribed painkillers, according to the National Institute on Drug Abuse, the role that prescription medication plays in the overall crisis is significant and complex. The pain is real: more than one in ten U.S. adults live with chronic pain. But so is the abuse: 11.5 million Americans over 12 reported misusing prescription opioids in 2016.
Healthcare providers, seeking to do a better job of pain management and misled by a pharmaceutical industry that was soft-pedaling the dangers of addiction, helped plant the seeds of the crisis by adopting more liberal prescribing guidelines for opioids starting in the 1990s. Today, providers have both an obligation and an opportunity to stem the crisis and help its victims.
A complete solution is multi-faceted and will involve significant changes in laws and regulations, funding, and training, as this list of American Hospital Association priorities clearly shows. However, information technology available now can enable bold steps to curb over-prescribing, track the flow of opioid medications and keep them from falling into unauthorized hands, and recommend alternative treatments. As we acquire more information, new algorithms may help us predict which patients are most at risk to become addicted, improving our ability to target the use of these drugs to where they’re most needed and least likely to cause lasting harm.
There’s no shortage of resources to help us, from the CMS roadmap issued in June to the guide released in November by Electronic Health Records Association’s (EHRA) Opioid Crisis Task Force. EHRA is owned by Healthcare IT News parent HIMSS.
The EHRA guide - CDC Opioid Guideline Implementation Guide for Electronic Health Records - is filled with highly practical advice about how to use EHRs, today, to support clinicians and provider organizations in following each of the 12 prescribing guidelines developed in 2016 by the Centers for Disease Control. Health organization leaders should also monitor the activities of the recently formed Opioid Task Force of the College of Health Information Management Executives (CHIME).
The EHRA guide identifies these areas where properly configured EHRs can help:
Most major EHR vendors are members of the EHRA, and the guide received input from the American College of Emergency Physicians, the American College of Physicians, and the American Medical Association. Many vendors have already started implementing tools to help their clients follow the CDC guidelines. (Our organization, Cerner Corp., released its free opioid toolkit in October.)
But there’s only so much the clinician can do at the bedside or during an office visit. A fully effective strategy to combat opioid abuse needs arrangements and relationships that span providers and the community. When patients with an opioid addiction finally are ready to seek treatment, they can’t wait a week for a psych bed or three months to see a substance abuse specialist: if their provider organization can’t give them access to those things, it needs to know who can, and make the connection ASAP. It’s essential for clinicians to have access to the information other organizations may have on a patient’s opioid use; provider leadership must put necessary information-sharing agreements in place.
In our opinion, the following areas are ones where the top leadership in a healthcare organization must play a key role in leveraging information technology:
Tracking overall prescribing patterns and driving out variation. Prescribing clinicians should understand how they compare with their colleagues when it comes to prescribing opioids, and where they are falling into harmful habits. We worked with a provider organization where we reviewed data showing that one physician prescribed far more opioids than anyone else on the staff. The hospital administration pointed out that he was a pain and palliative care specialist, thinking that alone would explain the variation. And it would have—if we hadn’t excluded his pain and palliative care patients from the analysis. His prescribing habits from his palliative care practice had spilled over into how he treated his other patients, resulting in overprescribing. It took seeing how he compared with others to help him review and start changing his patterns.
Sharing information among organizations. State-level prescription drug monitoring programs (PDMP) are helpful for tracking which patients have received prescriptions for controlled substances, to prevent them from doubling up through multiple physicians or hospitals. PDMPs would be more helpful if providers, particularly those with multi-state service areas, could search reliably across state lines. There are gestures being made in that direction — 45 states are now cooperating to share PDMP data through the National Association of Boards of Pharmacy Interconnect Program— but a federal-level effort is needed to solve interoperability problems nationwide.
However, PDMPs were invented to solve one specific problem: an important one to be sure. But they are virtually worthless for the most urgent opioid-related patient-care issues: identifying people most at risk for addiction and those with active opioid use disorder, curbing overprescribing, or providing substance abuse treatment and effective non-opioid pain treatment. Sharing information about patients’ experience with opioids and addiction, whether or not they have active prescriptions, is absolutely essential. This sharing could be accomplished through state and regional health information exchanges and applications that aggregate patient data across providers. That information is, rightly, hedged with privacy safeguards both federally and at the state level, and it will take close collaboration with policymakers to figure out how to share information among providers in ways that help patients without compromising their privacy. Healthcare leaders should make it a top priority to participate in that conversation and push for action.
Promoting drug take-back programs. A significant percentage of opioid abuse begins when someone, often a teenager, takes leftover opioids prescribed for someone in their family. If your organization has a DEA-approved collection site, make sure clinicians instruct patients on its location and hours and remind them to dispose of their unused medications promptly, following up as necessary. If it doesn’t house a collection site, clinicians should provide patients with information for the nearest one. There is no reason why every patient-care area shouldn’t have signage like this FDA poster, making drug take-backs an everyday idea like washing hands or getting a flu shot. Reminders about take-back programs can also be highlighted through provider patient portals. Unlike so many solutions to difficult problems, this one costs almost nothing except a few tweaks to clinical reminders and some focused institutional will.
Creating institutional policies that minimize the number of opioids in circulation. Fewer patients will have leftover opioids if they receive fewer pills to begin with. Some studies show that up to 90 percent of patients who receive opioid prescriptions don’t finish them, and a substantial number don’t even start them. Providers should look at instituting protocols to reduce the number of pills in an initial opioid prescription, with an option to request a refill if necessary. Prescription data will show how many patients filled that second prescription, allowing the protocol to be adjusted if necessary. Opioids should also be removed from automatic ordering: for example, for post-surgery pain. When queried, patients may reveal that they don’t want or need the medication. Even if they do, the few minutes the clinician spends considering the prescription may lead to a smaller initial number of pills and some valuable patient education on use, storage, and disposal. This protocol from Intermountain Healthcare may provide a starting point for discussion.
Expanding access to substance-abuse treatment services. Adequate access to services is an essential part of an effective opioid abuse reduction strategy. There’s no quick, easy, inexpensive solution to the shortage of services in many areas. But at a minimum, all healthcare providers in a given service area should explore ways to coordinate access to the substance abuse services they offer, so that if there is an empty bed or a counseling slot available, a referring organization can locate it without delay.
As our prowess at applying analytics increases, we are likely to see predictive analytics that can use a wide range of variables to identify individuals who have elevated addiction risks and/or may be struggling with recovery. These variables will include core clinical data, family history, social determinants, and genetic data.
Opioid addiction is a very complex and difficult challenge. Addressing this challenge requires societal, political and organizational will and resources. Information technology can play an important role, using electronic health records, clinical decision support, analytics, patient portals, interoperability and the expansion of our clinical information systems to incorporate social determinants of health. We in the healthcare community have the tools and the data to make a significant impact on our country’s tragic opioid abuse epidemic.
John Glaser is senior vice president of population health at Cerner, where Michael Fadden is the chief medical officer.
Healthcare IT News is a HIMSS Media publication.
Despite all the progress with EHR adoption, a new report from the Office of the National Coordinator for Health IT (ONC) shows hospitals are still using faxes to share information and most of them are still wrangling multiple electronic health record systems.
Hospital health information exchange is complex, involving a variety of methods, according to ONC, which used data gathered from hospital CIOs in partnership with the American Hospital Association between January and mid-May of this year.
The study also showed: half of hospitals used four or more electronic methods to send summary of care records, one-third used more than three and nine out of 10 hospitals that used at least six different electronic methods said their clinicians have information electronically available at the point of care.
What's more, Healthcare IT News sister company HIMSS Analytics found earlier this year that healthcare providers have an average of 16 EMRs across their affiliated practices.
When it comes to exchange outside of the hospital, most are using a variety of electronic methods, including HISPs, national networks, or state, regional and local HIOs. HISPs were used by most hospitals for sending (68 percent) or receiving (49 percent) summary of care records, ONC said.
WHY IT MATTERS
Most experts and federal officials believe healthcare providers could advance the efforts of information exchange with the use of national networks. Hospitals are taking to health information networks, with 71 percent participating in at least one national network, ONC found.
This includes Surescripts, a third-party intermediary that enables the exchange of prescriptions and medication-related data. Excluding Surescripts, about half of hospitals participated in at least one national network.
In this latest report, ONC said the Trusted Exchange Framework might help to simplify the exchange of health information through the use of health information networks.
The report follows an Oct. 29 ONC report, which showed that hospitals are making strides on EHR adoptions and interoperability— but work remains. More than 90 percent of non-federal acute care hospitals are using 2015 edition certified technology or plan to be soon, says National Coordinator Don Rucker, MD.
THE BIGGER TREND
Yet despite the widespread EHR adoption, the latest KLAS report says governance and organizations dragging their feet on participating in new national interoperability frameworks, such as the CommonWell-Carequality link, is holding back interoperability.
KLAS says that as of now, all of the most prevalent EHR vendors except Allscripts and MEDHOST are connected to the national framework provided by CommonWell-Carequality – "putting the ability to exchange patient records within the reach of most acute care or clinic-based provider organizations, regardless of size or financial situation."
The interoperability challenge of exchanging information among healthcare provider’s medical record systems is not being solved fast enough, which is why fax is still the common denominator for communications within and between providers and payers in the healthcare industry. But times are changing-- Alternatives exist that can provide a safe and secure transfer of healthcare data.
The report, tabled by the Queensland Audit Office (QAO), highlighted the benefits of the digital hospital program in Queensland, while making recommendations to improve governance of the future rollout.
Key findings from the report identified that as a result of the digital hospital program, Queenslanders face improved health service delivery and patient outcomes, as well as a reduction in unplanned readmission rates.
It found that medical staff can access clinical information faster and that patient records are more legible.
Minister for Health and Ambulance Services Steven Miles said the digital hospital program is “one of the most significant health advances in decades”.
“Digital hospitals are making Queensland hospitals safer than ever before. Doctors and nurses have told me when I’ve visited hospitals that the digital system helps them do their jobs and helps patients,” Miles said.
Miles brought up the example of Metro South Health’s digital program, which he said contributed to a “significant increase” in early identification of deteriorating patients, as well as a decrease in emergency patient readmissions, less incidents linked to drug administration, monitoring, dispensing and supply and a significant drop in infections.
As part of its move to digital, the healthcare provider most recently embarked on a journey to enable people living with progressive neurological conditions like Motor Neuron Disease (MND) to use mobile digital assistants daily.
The report also identified the benefits that Princess Alexandra Hospital has faced and how it has become a template for the rest of the state following its adoption of an integrated electronic medical record (ieMR) system.
“We can see digital hospitals are reducing the average length of stay and unplanned readmissions,” Queensland Chief Clinical Information Officer Dr Keith McNeil said. “Doctors are telling us the new system means they can spend more time on patient care and less time on paperwork.
“Nurses are saying that the system means they have a huge amount of readily available information and they are not having to waste time searching for notes. This means the system is working.”
He added that the increasing focus on technological advances and continuing improvements will continue to provide new opportunities. “Our increased focus on ieMR’s clinical capability will ensure our patients can access these opportunities, now and in the future.”
The report also found that while implementation costs exceeded initial expectations, it was often because hospitals spent more to go beyond the planned scope of their digital hospitals, bought extra devices to increase utilisation of the systems and invested more resources to reduce disruption on patient flow when new systems were introduced.
Queensland Health Director-General Michael Walsh has reviewed the status of the system rollout and has made a number of changes relating to report recommendations.
Walsh said the system was in place in 10 hospitals across the state’s Hospital and Health Services and that the department would continue to focus on ensuring the system delivered on benefits.
He said Queensland Health has expanded the responsibility for managing the relationship with the digital hospital system provider and commenced an independent assessment to confirm that, as per the contract, the prices being paid for the system were no less favourable than those being paid by other health service providers in Australia.
“The people of Queensland expect and deserve the very best care when they are treated in the state’s hospitals,” Walsh said.
“The report confirms the system is helping us deliver that and we accept the system-oversight recommendations the QAO has made. They are not difficult to implement because they are not major adjustments.”