Providers and vendors team up for user-friendly EHRs

Before an Allscripts electronic health record appears on screen, it first appears on a storyboard—sometimes even a paper one. That’s where Allscripts developers can test new ideas on providers, figuring out what should go where.

“The design on paper is still at the basic level where we can change on a dime,” said Ross Teague, director of user experience for Allscripts Healthcare Solutions. Users usually feel more comfortable offering feedback on a design when it looks unfinished.


THE TAKEAWAYElectronic health records are notoriously clunky. Vendors, with the help of their provider clients, are out to change that.
Such interaction is crucial, given that clinicians spend about half the workday working with EHRs. And many of those hours are during patient encounters. A study in the Annals of Internal Medicine found that ambulatory physicians spent more than a third of their time with patients on EHR and desk work tasks. That makes many providers unhappy, and not just because it affects their face-to-face time with patients.

“The challenge of established EHRs is that so much functionality gets piled onto these complex systems,” said Dr. Titus Schleyer, a research scientist with the Regenstrief Institute.

But as providers complain, vendors respond. Allscripts, Athenahealth, Cerner Corp. and Epic Systems Corp. are among those constantly tweaking their software after getting feedback from the source of those complaints. They’re consulting with and observing users inside and outside of their natural work environments to build EHRs for efficient—and pleasant—workflows, layouts and functionality.

Most, if not all, major EHR vendors rely on a combination of formal user testing, informal feedback, and what might be called ethnographic research. The result isn’t just happier clinicians but safer healthcare delivery.

“Many of the same issues that can lead to clinician frustration with EHRs can also lead to safety problems,” said Ben Moscovitch, manager of health information technology for the Pew Charitable Trusts. For instance, if a clinician accidentally orders a medication for the wrong patient, correcting the error can be cumbersome, requiring multiple steps, he said. The EHR can be tweaked to address that.


A partnership

With healthcare perpetually inching toward value-based care, EHRs are more important than ever in helping patient care. Vendors are working with providers to improve their offerings, going beyond meeting the bare minimum federal requirements for their software.

Athenahealth, Allscripts and others have formal programs to gain insight from their provider users both while software is in development and after. “That relationship has really improved the way the system works for us and, I would presume, because of the way Athena works, for all of its customers,” said Steven Kelley, CEO of Ellenville (N.Y.) Regional Hospital, which, as an Athenahealth development partner, tries out prototypes with new features.

That kind of relationship also helps vendors, which learn from their users early on what kinds of features they’re interested in and how those features should work.

“In a good user-centered design process, you’re involving your users early and often,” Allscripts’ Teague said. His company does formative testing with its users during which they engage in the aforementioned and try new versions of the software. “This is the No. 1 method by which we collect patient-safety issues before they ever become patient-safety issues,” he said.

Allscripts also gets new product ideas by observing clinicians in care settings. Sometimes, for instance, to get an objective sense of how well its software works, Allscripts will measure how many users can complete a certain task without any training.

Observational research is particularly helpful given how providers talk about what they want from their EHRs. “Sometimes, what people say only reflects part of what their goal is,” said Janet Campbell, Epic’s vice president of patient engagement. “If you give a doctor a list of 10 activities in the record and you say, ‘How many of these would you like to see on the screen?’ they’ll say, ‘All,’ ” she said. “It’s not until you watch how they interact and move back and forth that you realize that they only need three of those things.”

When Athenahealth is testing a feature in the alpha or beta stage, the company uses behavioral analytics to glean how users are interacting with it. “One of the benefits of being cloud-based is that all the data across our network is very accessible, and we can see the actions people are taking,” said Scott Mackie, Athenahealth’s executive director of strategy design and user experience.

For instance, when the company was developing a timeline feature, users complained about how many clicks it took to see everything that had happened to a patient over time. Athenahealth developers watched how the timeline affected workflow so developers could lay it out to highlight the most useful and appropriate events and data. Giving clinicians the information they need when they need it could help them better care for patients, since it would reduce their workload and help identify important elements quickly. “Physicians want the right information at the right time at the right point of care, and that helps them provide better care,” said Rich Berner, Allscripts’ senior vice president of health systems and population health solutions management.

Presenting information, not data

Part of the reason vendors must revise and tweak EHRs is because of their complexity, Schleyer said. It’s hard to design a program that’s usable “right out of the box.”

To deliver a more consistent patient and user experience across its facilities, SSM Health consolidated its three versions of Epic into one. “We called the project that we worked on ‘simple elegance,’ ” said Philip Loftus, SSM’s chief information officer. “If it took you five screens to do something, we tried to bring that down to two or three screens.”

The improvements came from Epic’s collaboration with SSM and from SSM’s own developers, who get regular feedback from physicians and from consumers surveyed after the health system updates software.

One request was to display all information relevant to patients’ care on one screen.

Physicians want all of that information at the top level, Mackie said. “They want less digging,” he said. A solution could be building artificial intelligence into the EHR so it learns the most important information, he said. Another solution might be voice, especially as it becomes more common in consumer life.

Increased population health efforts also have vendors considering how new kinds of data should be presented.

“People aren’t asking for data—they’re asking for information,” Teague said. “That means fitting it into their workflow and making sure it’s presented in a way where they’re not spending a lot of cognitive effort determining what it means.”

Top heart hospitals zero in on continuum of care

Before cardiac surgery patients are discharged from St. Luke’s Boise (Idaho) Medical Center, they are referred to the hospital’s cardiac rehabilitation program.

The 12-week program offers routine monitoring by clinicians for patients who recently underwent open-heart surgery, a valve replacement or any other type of cardiac procedure.

The rehab center is staffed with a multidisciplinary team of healthcare professionals including physicians, nurses, respiratory therapists, dietitians and social workers. The program provides patients additional education about their disease, help with personal issues that might prevent them from following the treatment plan, and exercise and nutrition courses that can help speed their recovery.

About 95% of cardiac surgery patients enroll in the program, and it has contributed to lower readmissions since it launched in 2009. About 14.7% of heart attack patients are readmitted to the hospital after 30 days, below the national average of 16.8%.

“We try to standardize follow-up within our practice,” said Dr. Stefanie Fry, chair of the department of cardiovascular services at St. Luke’s Boise.

The sharp focus on ways to address every aspect of the care continuum is a hallmark strategy of St. Luke’s Boise and other hospitals recognized this year in the Watson Health 50 Top Cardiovascular Hospitals (formerly known as the Truven Health 50 Top Cardiovascular Hospitals) study. Hospitals considered to be leaders in cardiac care standardize and invest in approaches that not only improve the health of their patients during their inpatient stay but long after discharge as well.

Focus on the continuum of care is in line with the move to value-based payment, said Jean Chenoweth, senior vice president of the Center for Performance Improvement at IBM Watson Health.

“Value is starting to increase over time,” Chenoweth said. “When hospitals are focused on the continuum of care and they don’t let it go, they maintain their focus on that quality of care and the industry changes as a whole.”

The 19th annual study reviewed 1,016 hospitals and recognized 50 that provide exemplary care in one of the industry’s largest specialties. Heart disease is the leading cause of death for men and women in the U.S., accounting for 1 in 4 deaths every year. And each year about 735,000 Americans have a heart attack, according to the Centers for Disease Control and Prevention.

The 50 hospitals on Watson Health’s list scored higher than their peers on clinical outcomes for heart attack and heart failure treatments, as well as coronary bypass and angioplasty surgeries. The hospitals performed better on mortality and complications, as well as 30-day mortality and readmissions. On average, their procedures cost less and patients had shorter hospitals stays.

Similar to previous years, Watson Health divided the top hospitals into three categories—15 teaching hospitals with a cardiovascular residency program, 20 teaching hospitals without such residency programs and 15 community hospitals.

To get its results, Watson Health uses the most recent CMS data from the Medicare Provider Analysis and Review file, CMS Hospital Compare and Medicare cost reports. Watson Health also added two new measures this year to its analysis: 30-day episode payment for heart attack and heart failure patients. The additional measures reflect the movement toward population health management as hospitals are expected to manage the quality of care of patients after discharge, said Julie Shook, 100 Top program director of value-based care at Watson Health.

Chenoweth said it’s increasingly difficult for 50 Top hospitals to beat their peers because cardiovascular care overall is improving. Indeed, the 50 Top hospitals performed less than 1% better than peers on 30-day mortality and readmission rates for heart failure, heart attack and coronary artery bypass surgery patients.

“The fact is quality is improving in cardiovascular care over time,” Chenoweth said. “The hospitals are benefiting from newer technology and treatments.”

The vast majority of the 50 hospitals being recognized for their cardiac care were veterans on the list, but there were also eight newcomers, including Wake Forest Baptist Medical Center, a teaching hospital in Winston-Salem, N.C. The hospital has recently focused on ways to prevent costly readmissions and streamline post-discharge care among its heart patients, said Dr. David Zhao, chief of cardiovascular medicine at Wake Forest.

In 2014, the hospital began to incorporate pharmacy technicians into the discharge protocol. The patients receive a 30-day supply of their prescribed medication before they leave the hospital, up from just a seven-day supply. The longer time period ensures patients stick to their medication regimen and have time to sort out a prescription refill, Zhao said.

Additionally, 48 hours after patients are discharged, a nurse calls to check in on their health status and to make sure they are following the care plan. A mandatory follow-up appointment also occurs at the hospital seven days after discharge.

The hospital has seen its readmissions rate fall since the initiative was launched. “We can understand if there are issues medication-wise, or with their living circumstances like transportation—those are things we can catch earlier and intervene so they won’t be readmitted,” Zhao said.

But ensuring appropriate follow-up with patients after discharge isn’t without challenges. Wake Forest cares for a large rural and Medicaid population, so the hospital needs to coordinate care for complex patients, Zhao said.

“Enough manpower has always been a challenge,” he said. “Who is going to make phone calls to patients and make sure they can care for themselves?”

Anthem CEO Joseph Swedish to retire

Joseph Swedish is retiring from his post as CEO of Anthem, the second-largest health insurer in the nation.  Swedish will be succeeded by Gail Boudreaux, the former CEO of UnitedHealth Group’s insurance arm.   The leadership shift has been in the works for a year, Swedish said, and the company plans to make the announcement Monday. It is unclear when the official transition will occur.

Swedish’s career in healthcare spans more than four decades. He has worked for Indianapolis-based Anthem, a licensee of the Blue Cross Blue Shield Association, since 2013 when he replaced Angela Braly as president and CEO. He became chairman in 2015.  Before Anthem, Swedish was CEO of Livonia, Mich.-based Catholic hospital system Trinity Health, an office he took in 2004.

During his tenure, Swedish saw Anthem’s annual revenue balloon from $71 billion in 2013 to $84.9 billion in 2016. Anthem serves about 40 million members in 14 states.

He led the insurer in its effort to acquire rival insurer Cigna Corp. in a deal valued at $54.2 billion. The contentious tie-up was ultimately abandoned after being challenged by the U.S. Department of Justicce for threatening to harm competition.

Anthem last month announced the formation of its own pharmacy benefit manager, IngenioRx, in the wake up its fallout with long-term PBM partner Express Scripts.

Swedish made $16.5 million in total compensation in 2016, according to documents filed with the SEC.

Delivery system reform hampers ACO progress on risk-based contracts

Accountable-care organizations are participating more and more in risk-based contracts, but that progress has been stalled by sluggish care-delivery changes, a new survey suggests.

Roughly 50% of ACOs are involved in at least one downside risk contract, such as shared savings and capitation contracts, according to a Leavitt Partners and National Association of ACOs report recently published in Health Affairs. About 47% of ACOs plan to participate in shared-savings risk-based contracts in the next year or so.

However, ACOs are focusing mostly on “low-hanging fruit” strategies to save money and improve quality of care, which mitigates how well the organizations are able to perform in riskier contracts, the report said.

“Even though ACO providers say they are preparing for and assuming risk, the care delivery system is not advancing as quickly as the payment system reforms,” said Kate de Lisle, an author of the study and a senior analyst at Leavitt Partners. “In order for these payment models to be successful, providers need to change the way they deliver care.”

Most ACOs still largely focus on “first wave” care delivery changes like readmissions, emergency department use and chronic care management, the report said. ACOs haven’t yet tapped into other reforms that will also help them prepare for downside risk like behavioral health integration and medication optimization and management.

Behavioral health and medication management contribute to high healthcare costs, and ACOs farther along in the model have started to address those aspects of care, de Lisle said.

Approximately one-quarter of all ACOs, or 240, responded to the survey. The respondents ranged from urban to rural ACOs as well as physician-led, hospital-led and integrated ACOs.

The survey found that hospital-led ACOs are more likely to have a shared-savings contract with downside risk than a physician-led contract. About 48% of hospital-led ACOs said they currently had a risk-based contract, compared to 28% of physician-led ACOs. Physician-led ACOs might have stalled because they have fewer resources than large systems to secure the capital needed to participate in risk-based contracts, de Lisle said.

“Though the physician-led ACOs have fewer active shared-loss contracts, they are still planning to participate, they are just behind a little bit,” she said.

Previous research has even shown that physician-led ACOs are more likely to be successful in the model because they have a deep understanding of their patient populations, she added.

But delivery system reform hasn’t kept pace with payment reform. The CMS and other payers haven’t offered providers much of a road map for adopting changes to care management. As a result, physicians are trying many different tactics all at once to see what does and doesn’t work, de Lisle said.

That hasn’t stopped providers with several years of ACO experience from generating savings. A recent study from HHS’ Office of Inspector General found the 423 ACOs participating in the CMS’ Medicare shared-savings program reduced spending by about $1 billion in three years.

De Lisle encouraged providers to keep working at their ACOs and to not give up. “The longer you are working with these goals and align your system, you begin to figure it out,” she said.

The survey also revealed that ACOs spend an average of $1.1 million on care management, and nearly all ACOs — 95% — use care coordinators to help manage their patient population.

“Care coordinators are these Swiss army knife team members that can be used in a number of ways,” de Lisle said.

The ACO model is by the far the most popular in the push to value-based care. As of the first quarter of 2017, 923 private and public ACOs were in operation, covering more than 32 million patients, according to a June 2017 post in Health Affairs by Leavitt Partners.

“Because the ACO model has been the primary vehicle in value-based care, I think studying the ACO movement will allow us to better understand where we are on the broader spectrum,” de Lisle said.

By Modern Healthcare.

Hawaii Medicaid waiver seeks reimbursement for helping house the homeless

Hawaii has asked the CMS to help it care for chronically homeless people more efficiently by addressing a major social determinant of health: housing.

The state’s waiver asks for federal reimbursement for Hawaii’s efforts to help homeless Medicaid recipients find and maintain housing. Both states and providers are looking for new ways to address social issues that undermine patients’ health and care plans.

Hawaii wants to use federal Medicaid funds to appoint state employees to help people find housing and provide moving assistance to those beneficiaries, according to a pending waiver application now under CMS review. The state has one of the highest homeless populations in the country.

Hawaii also wants to be reimbursed for providing tenant support services, such as conflict management training between enrollees and landlords.

“We anticipate that by providing these services, we will not only reduce our health costs, but we will help reduce people suffering from chronic homelessness, which ultimately saves lives,” said Judy Mohr Peterson, the state’s Medicaid director.

The waiver doesn’t ask Medicaid to cover actual housing costs, which is prohibited by federal law.

Hawaii hopes to build off its success with the state-funded Housing First program that started in 2014. The initiative focused on helping homeless people in the Honolulu area, and helped decrease healthcare costs for people in the program from an average of $10,570 per client per month to $5,980 per client per month.

For doctors, stable housing means there is a greater likelihood patients will adhere to their medication regimen and comply with preventive care recommendations.

Many of Hawaii’s homeless have very poor health and suffer from issues including diabetes, renal failure and heart disease. These conditions need preventive care and ongoing monitoring to prevent longer-term, more challenging and costly medical care, like dialysis or amputations, according to Dr. Scott Miscovich, a family medicine practitioner in Kaneohe, Hawaii.

“Having a home or reliable location to find a complicated patient with multiple comorbidities allows for outreach including home health services or case management,” Miscovich said.

Other states like California, Maryland, New York, Oregon and Washington have convinced the CMS to pay for housing support service initiatives, but Hawaii’s waiver is unique. The state’s request targets people who are at risk or currently are homeless and also have significant health needs, according to Peggy Bailey, director of the health integration project at the Center on Budget and Policy Priorities.

“Providers often struggle with finding funding sources to pay for the intensive support services that keep people with significant behavioral or physical health needs in housing,” Bailey said. “Medicaid financing would make a huge difference in the state’s efforts to end homelessness.”

It’s unclear whether the Trump administration will approve the waiver. Other state waivers that included similar housing provisions were approved by the Obama administration, Bailey said.

HHS Secretary Dr. Tom Price has made clear he is looking to cut Medicaid spending. However, Hawaii officials hope that the long-term healthcare savings will be enough to get the request approved.

“Republicans would agree that if we have a better model that saves money that’s good,” said state Sen. Josh Green, who is also a practicing emergency room physician. “I hope that the administration will see this as an opportunity.”

The CMS will accepts comments on the waiver request through Oct. 17.

Ascension to acquire Presence Health

Chicago-based Presence Health has signed a letter of intent to merge into Ascension, combining the largest Catholic-sponsored healthcare system in Illinois with the nation’s largest Catholic health system, the companies announced Tuesday.

If the deal is completed, 12-hospital Presence will be owned by Ascension but operate in a joint venture called Amita Health that Ascension already has with Adventist Midwest Health.

Only Presence’s senior-care unit, Presence Life Connections, will be integrated into Ascension, the companies said in a release Tuesday.

“We believe this will strengthen Catholic healthcare not only in the region but throughout the country as we are all dedicated to delivering personalized, compassionate care,” Ascension CEO Tony Tersigni said in a statement.

Presence heads into the deal with a two-year turnaround effort still trying to get traction in the intensely competitive Chicago hospital market.

Presence posted an operating loss of $40 million in 2016, far better than the $186 million operating loss in 2015. But it was still short of system targets, Presence CEO Mike Englehart recently said.

In the first quarter, Presence returned to the black operationally, posting an operating gain of $12.4 million on revenue of $661.4 million.

Its 10% market share will now be combined into Amita Health, a 2-year-old joint venture that encompasses nine hospitals and a large physician network across the western and northwestern suburbs of Chicago.

Amita is an operating tie-up between Hinsdale, Ill.-based Adventist Midwest Health and Ascension’s Alexian Brothers Health System, based in Arlington Heights, Ill.

The new deal with Ascension is not expected to affect an agreement that Presence recently inked to divest two downstate hospitals to Peoria-based OSF HealthCare: Presence Covenant Medical Center in Urbana and Presence United Samaritans Medical Center in Danville.

That deal is expected to be completed in early 2018 but is subject to regulatory approvals.

For Ascension, the Presence acquisition is its largest deal since acquiring financially healthy Wheaton Franciscan Healthcare of Milwaukee in March 2016.

Tersigni has in numerous interviews stressed his personal commitment to strengthening and expanding Catholic healthcare wherever Ascension is needed.

Ascension and Presence executives would not comment Tuesday beyond their news release.

Ascension is the nation’s largest not-for-profit hospital company, with 141 hospitals and fiscal 2016 revenue of $21.9 billion.

Two other Catholic healthcare giants, Dignity Health and Catholic Health Initiatives, are discussing a merger to see if they can operate more efficiently together than apart.

Presence beat long odds a year ago when, in the face of its large 2015 operating losses, Englehart and his financial staff were able to pull off an outsized $1 billion bond offering that provided the financial flexibility to continue the system’s turnaround.

Cardinal Health profit declines as generic drug prices deflate

Cardinal Health reported an 18% drop in earnings in its fourth quarter, driven by dwindling generic drug prices, the company said Wednesday.

The Dublin, Ohio-based pharmaceutical and medical products distributor saw its earnings fall to $274 million for the quarter ended June 30, down from $333 million from the same period the year before. Revenue was up 5% to $33 billion.

Cardinal’s pharmaceutical segment profit dropped 7% to $505 million, largely due to deflating generic drug prices and ongoing investment in its pharmaceutical IT platform, the company said. Fourth quarter revenue for its pharmaceutical business was up 5% to $29.6 billion, helped along by a growing customer base and a boost from its specialty products.

On the year, Cardinal’s pharmaceutical segment profit decreased 12% due to declining generic prices, a lost drug distribution contract with Safeway and a slowdown in price increases for branded drugs. Cardinal’s rival McKesson Corp. also cited the sluggish branded drug price increases as a cause of its diminished profit last week. Companies along the pharmaceutical supply chain have taken a financial hit resulting from the increasing scrutiny surrounding surging drug prices.

“While these last 12 months were clearly a dynamic period in healthcare and certainly presented challenges for our fiscal 17, it was also a year in which we took important actions to strengthen our market positioning, grow our scale, add new, long-term drivers of growth, and improve the overall balance of our integrated portfolio,” George Barrett, chairman and CEO of Cardinal Health, said in a statement.

Cardinal scaled up when it closed its $6.1 billion acquisition of Medtronic’s patient care, deep vein thrombosis and nutritional insufficiency business Monday, which will likely bolster its medical supply segment.

Fourth quarter profit for Cardinal’s medical supply segment jumped 13% to $138 million on revenue of $3.4 billion, a 6% increase from the fourth quarter last year, led by positive post-acute product performance and growth in distribution services, the company said.

On the year, profit for that segment increased by 25% to $572 million while revenue rose 9% to $13.5 billion.

Overall profit for fiscal year 2017 dropped 10% from 2016 to $1.29 billion and revenue increased 7% to $130 billion.

In April, the company cautioned that its 2018 outlook would reflect continued declines in generic drug prices, which could result in a drop in profit for the company’s pharmaceutical business. The company’s operating expectations have not meaningfully changed, Barrett said, but they are taking some “discrete actions” to improve its trajectory.

By Modern Health.