Blog from November, 2019

A study found that an EHR “nudge” increased breast cancer screenings by 22 percent and colorectal screenings by 14 percent.

Christopher Jason

With doctors’ busy schedules, a “nudge” is needed to prompt medical assistants to set up and order cancer screenings for doctors to sign once they see the patient, according to a study published in JAMA Network Open.

Researchers at Penn Medicine that specialize in EHR nudges found a 22 percent increase in screening orders for breast cancer and a 14 percent increase for those treating colorectal cancer. Overall, 88 percent of the breast cancer patients and 82 percent of colorectal patients included in the study had a cancer screening ordered due to the nudges.

Although the percentage of cancer screenings increased, there were minimal changes in the rates of patients who followed through within one year and completed their screenings. Researchers concluded that further interventions may need to be targeted to patients to complete their screenings.

“Cancer screening involves both the clinician recommending and ordering it as well as the patient taking action to schedule and complete it. Our study found nudges can be very influential, but for cancer screening they likely need to be directed to both clinicians and patients,” said Mitesh Patel, MD, MBA, director of the Penn Medicine Nudge Unit and the senior author of the study.

The study of nearly 70,000 breast or colorectal cancer patients at 25 primary care practices looked at how doctors can use the EHR to increase the rate at which they screen patients for the disease.

 “Clinicians are increasingly being asked to do more with a fixed amount of time with a patient,” said Esther Hsiang, the study’s lead author. “By directing the intervention to medical assistants, this reduced the burden on busy clinicians to respond to alerts and instead gave them more time to have a discussion with their patients about screening.”

In the study, the nudge was directed only to medical assistants who could create orders for clinicians to review. The medical assistants would then inform the patients that they were eligible for cancer screening and should discuss screening with their clinician. Researchers targeted medical assistants specifically to account for physician burnout challenges and EHR complexity that often bogs down physicians.

This study design lessened the burden for physicians and encouraged patients to prioritize a discussing a cancer screening. However, due to the more arduous process for completing a screening order – patients usually have to schedule a second appointment – patients did not necessarily respond to the prompts.

“Once cancer screening is ordered, the patient still has to take several steps to complete it,” explained Patel. “That includes scheduling an appointment, sometimes conducting prep — such as bowel prep for a colonoscopy — and then going to the appointment. These several steps can add up to high hurdles, especially if patients have lower motivation to begin with. Future interventions should test ways to nudge patients to complete cancer screenings.”

Patel and his team are in the process of developing a new study to test nudges for both the clinicians and the patients to increase the likelihood of patients to follow through and complete their screenings. The researchers also want to branch out and gain more data from more than the two types of cancer that they initially focused on.

“Since EHRs are used by more than 90 percent of physicians, this is a really scalable approach,” Patel concluded. “It is likely that it could be successful for other types of screening.”

Care coordination and interoperability between health data strengthens levels of care and reduces healthcare costs.

Christopher Jason

Driving care coordination is essential to providing a quality patient experience, helping to tie together patient care at the many healthcare facilities she may visit. But limited health data and EHR interoperability can get in the way, limiting providers’ ability to access patient information from disparate facilities.

Interoperability enables care coordination to deliver a patient’s health data from multiple providers and specialists. With patients attending different hospitals and specialists, the need for interoperability between multiple providers is key. Coordinated care reduces healthcare costs by eliminating repetitive tests and procedures.

Strong EHR use is found at the primary care level. However, it is still a work in progress at acute and post-acute hospitals.

Care coordination crucial to cohesive primary care

Strong EHR use is key for better care coordination between primary care and behavioral health specialists, said researchers in a 2017 study published in the Journal of the American Board of Family Medicine.

The study found that 67 percent of individuals with behavioral health (BH) disorders do not receive the care that they need, but when their care is integrated into the primary care setting, that issue typically improves.

“Most patients with BH conditions, including children, are seen in medical settings, most commonly primary care (PC), presenting the need and opportunity to replace separated systems of care that do not adequately meet the needs of patients with integrated, ‘whole-person’ care,” the researchers explained.

Integrating and coordinating specialty care — in this case behavioral healthcare — into primary care relies on EHR use and interoperability. Interoperable systems allow providers to access valuable clinical information from other providers who have previously treated the patient.

“Establish standard processes and infrastructure necessary for your integrated care approach: workflows, protocols for scheduling and staffing, documentation procedures, and an integrated EHR,” the researchers recommended.

And ultimately, this will streamline patient care. Interoperable systems between specialty and primary care providers ensures the specialty provider understands the patient’s current health conditions and can make informed medical decisions.

For example, when specialty providers can access the patient’s complete medical history, they can avoid re-testing and ensure that the patient receives the best care right away.

“This allows the caregiver to quickly find information about that patient and who’s responsible for them,” Mobile Heartbeat Vice President Jamie Brasseal told “Providers can communicate with the appropriate colleagues — such as specialists or pharmacists or case mangers — very quickly, and without having to leave the patient’s bedside, or go search for that information at the nursing unit or in the EHR.”

Care coordination improving at acute care hospitals

Patients do not always receive acute or emergency healthcare in the same facility where they receive their primary care, which can create some data exchange challenges for acute care providers. With patient data stored in disparate systems, acute care providers can be left without critical information off of which they can base medical decisions.

In a recent survey from PointClickCare, 49 percent of acute care providers said they have very little ability to access or share patient data electronically, resulting in a struggle for providers.

“With better communication between the facilities, we would cut back on readmission and sending patients back to the ER and any sort of miscommunication,” said one participating hospital executive.

Reassuringly, many acute care hospitals are investing and focusing more on improving its data exchange efforts.

Seventy-three percent of acute care providers said they are putting a higher priority on implementing interoperable systems for transferring patients.

“Streamlining interoperability between systems creates huge opportunities for cost reduction, patient care improvement and reduced workloads for people on both ends of patient transfers,” researchers said.

“This type of health data exchange also helps improve the transparency of data between acute care and skilled nursing facilities, enabling a stronger relationship. And, it enables robust, population health capabilities that are scalable as the number of patients needing post-acute care grows.”

In a 2018 report from the ONC, 83 percent of hospitals that had the capabilities to send, receive, locate, and integrate patient health information from outside organizations into their EHR systems reported having the ability to access information electronically at the point of care.

“This is at least 20 percent higher than hospitals that engage in three domains and almost seven times higher than hospitals that don’t engage in any domain,” wrote Don Rucker, MD, national coordinator for health IT and Talisha Searcy, director of research and evaluation.

Educating the staff and providers on EHR use and information exchange will benefit the team in the long run and provide better care for patients in acute care

Promoting better EHR adoption in post-acute care

Interoperability challenges can follow patients and providers out of the hospital and into the rehabilitation process. Provider access to information about a patient’s acute hospital stay will be integral to quality post-acute care, but many providers see bumps along the road.

That same PointClickCare survey revealed that 84 percent of post-acute care organizations are still using at least some manual processes to exchange patient data with acute care hospitals. Organizations relying on fax, email, and paper-based solutions to exchange patient data could encounter mistakes, mismatched patient data, or omissions that could seriously hinder patient care.

But the Centers for Medicare & Medicaid Services (CMS) is working to address that gap.

After prompting nearly universal EHR adoption in acute care facilities, CMS is promoting widespread EHR adoption in post-acute care (PAC) settings.

In March 2019, the federal agency released a request for information (RFI) seeking input about the best ways to incentivize EHR adoption and use among providers in the post-acute setting

“PAC facilities are critical in the care of patients’ post-hospital discharge and can be a determining step in the health progress for those patients,” stated CMS in the RFI.

“Interoperable health IT can improve the ability of these facilities to coordinate and provide care; however, long-term care and PAC providers, such as nursing homes, home health agencies, long-term care providers, and others, were not eligible for the EHR Incentive Programs under the HITECH Act,” the federal agency explained.

CMS partly attributes the slow rate of EHR adoption in PAC settings to the lack of federal incentives available to PAC providers.

Nearly 65 percent of skilled nursing facilities used an EHR system in 2016, but rates of health data exchange remained low among this population of providers. Only 30 percent of skilled nursing facilities participated in health data exchange, and only seven percent had the ability to locate and integrate patient health data into patient EHRs.

The inconsistency between rates of EHR adoption in acute and ambulatory care settings and PAC facilities partly contributes to problems with transitions of care.

“For PAC facilities that do possess EHRs, vendor adoption of interoperable functionality has been slow and uneven,” stated CMS.

As the medical industry continues to become increasingly digital and complex, it will be essential for disparate organizations to have systems for exchanging data. Interoperable tools will help drive care coordination between primary care providers, specialists, and acute and post-acute care organizations. And in doing so, clinicians can work to drive whole-person health and efficient, quality care.

Stephen Lawless

When you bring your loved one to the hospital, you expect them to get better, not worse.

But too often, we are failing at this crucial task. Too often, we hear about a patient admitted to the hospital who is seemingly doing fine, and then suddenly goes downhill. The question is “How did they get worse right under our eyes?”

How do we prevent someone from getting much sicker without us even realizing it?

Sepsis kills almost 5,000 children annually in the U.S.—more than cancer—and costs about $7.3 billion for hospitalizations alone. This huge and growing burden is now the most expensive cause of hospitalization in the U.S., with a high fatality rate that makes early recognition of patient instability absolutely critical. 

Innovation has finally caught up to this age-old issue by harnessing the power of predictive analytics. Three years ago, at Nemours Children’s Health System, a multidisciplinary system-wide team built a sepsis response tool that capitalizes on the health system’s technological resources.

Proprietary scoring criteria is built into the electronic health records to predict patient downturns before they happen. These stats are monitored by paramedics running the health system’s Clinical Logistics Center, a virtual command post that monitors every child seeking inpatient care at our free-standing children’s hospitals in Florida and Delaware.

Like air-traffic controllers peering into multiple video monitors, our team of paramedics and emergency nurses closely tracks color-coded vital signs in green, yellow or red to detect subtle changes in biomarkers that predict whether a patient is stable, declining or needs immediate attention. They triage alarms and can instantaneously initiate a rapid response team or even tap into a high-resolution audio/video connection, available in every room, to provide instant virtual care.

Machine learning and sophisticated algorithms that enable us to practice predictive analytics are not just aimed at speeding up our response to alarms. Our Clinical Logistics Center creates a smart support system that eases the alarm fatigue of nursing staff, acts as a fail-safe for patient care and can be a valuable planning tool to anticipate critical staffing needs in advance.

Nowadays, America’s hospitals have sicker patients on the general floors, patients who 20 years ago would have been in the ICU. Many of them are existing in what one expert calls “a precarious state of pseudo-stability,” and most hospitals are unprepared when they unexpectedly deteriorate and need instant, life-saving therapies. Without rapid intervention, patients who go into septic shock have an overall mortality rate of more than 50 percent.

Since we set up our response system at Nemours, we have had no unexpected deaths due to sepsis, largely because no alarms go unanswered for more than 90 seconds and no patients can suffer a severe downturn without staff being quickly alerted. Overall, we have reduced medication errors through decision supports, improved patient and nurse satisfaction rates, and, most importantly, we have dramatically lowered the frequency of sepsis from 2 percent to .05 percent.

Recently, we were honored to be the only pediatric health system invited by the Centers for Medicare and Medicaid Services to participate in a national sepsis “listening session” among subject-matter experts and leaders in the fields of innovation, care delivery reform and implementation science. CMS’s initiative is a most welcome development in promoting early identification of high-risk sepsis patients, speeding care delivery, and enhancing nutrition, mobility and other measures to improve quality of care.

Stakeholders in the fight against sepsis are encouraged by the emerging possibilities for using “big data” and artificial intelligence. CMS heard pleas for more funding towards awards and prizes that would foster these and other innovations. Participants called for raising community awareness and improving coordination between first responders and emergency departments.  

With the backing of federal, state and local health officials, and the willingness to promote coalition-building, we can replicate and expand upon the efforts that we and other healthcare systems have launched. We can create a better system that can be a model for fighting serious diseases and for saving lives.