Health IT

The Veterans Health Administration (VHA) is transitioning from its native electronic health record (EHR) Vista/Computerized Patient Record System to the commercial Cerner/Oracle Health EHR. Though this process was temporarily discontinued in April 2023 due to patient safety, usability, and reliability concerns, it resumed in April 2026. It was originally projected to cost $50 billion to implement. ^1-3 As of March 9, 2024, 6 sites had transitioned to the new EHR.² The transition is the largest of its kind in the US, offering an unparalleled opportunity to examine the effects of EHR transitions on an often overlooked part of the workforce: health professions trainees (HPTs).

HPTs serve a central role in VHA. About one-third of patients receive care directly from HPTs who make up about one-third of the VHA workforce. VHA trains > 60 clinical disciplines, comprising > 122,000 trainees annually.^4,5 A paucity of literature exists exploring the experiences of HPTs during EHR transitions, and many studies are often limited to single-site or small populations. HPTs face distinct challenges and needs during EHR transitions and are particularly vulnerable to their negative impacts on retention, clinical training, and efficiency and confidence in EHR use.^6-10 HPTs at VHA sites that have already transitioned to the Cerner/Oracle Health EHR identified many challenges, including significant delays in gaining EHR access, pervasive perceptions of poor training, concerns that EHR functionality issues limited patient care, and decreased ability to track clinical skill acquisition.⁶ These challenges may impact some HPTs more than others (eg, students on short rotations are affected more acutely by delayed EHR access and usage).

This quality improvement project evaluated HPT EHR transition experiences at the Captain James A. Lovell Federal Health Care Center (FHCC). This article contributes to the limited literature on HPT transition experiences, identifies opportunities to support HPTs, and informs broader efforts in teaching HPTs new technologies.

Methods

FHCC is jointly operated by the US Department of Defense and US Department of Veterans Affairs (VA). It treats 80,000 inpatient and outpatients annually. FHCC was the sixth VA facility to transition to the new EHR, which went live on March 9, 2024.^2,11 About 700 HPTs rotate through FHCC annually. HPTs were eligible for inclusion if they were present during the March 9 transition according to a VA Office of Academic Affiliations database. A total of 216 HPTs were identified for inclusion.

Preparations for the transition included scaling down operations (ie, blocking clinician schedules, not scheduling future appointments that may conflict with the transition, making decisions on new facility- and service-line workflows, required EHR training, and speaking with support staff, including VHA National EHR Modernization Supplemental Staffing Unit [NESSU]). This evaluation was designated nonresearch/quality improvement by the VA Bedford Healthcare System Institutional Review Board.

Surveys

Forty-seven interviews were conducted with HPTs, site leaders, and supervisors from January 2024 to June 2024 (Table 1). Participants were identified by service leads and recruited via email; snowball sampling identified additional participants.

The evaluation team developed semistructured interview guides using grounded probes based on a pilot evaluation and existing research on EHR transitions.¹² Questions focused on participant experiences preparing for the EHR transition, learning and using the site’s EHR, and the impact the transition had on clinical training experiences. Interviews were conducted at different times to capture the range of user experiences: 1 month prelaunch, 2 to 6 weeks postlaunch, and 2 months postlaunch. Interviewees were informed of participant rights and provided verbal consent.

HPTs present at FHCC at each survey’s release were emailed invitations and 2 reminders. The anonymous surveys took about 10 minutes to complete. Survey items queried HPTs about their experiences preparing to use the new EHR, perceptions of the current EHR (adapted from the System Usability Scale), satisfaction with VHA training, impact on clinical training, ability to work with preceptors and patients, and experiences with the VHA clinical learning environment (adapted from the VHA Learners Preceptor Survey).^13-15 Survey questions used a 5-point Likert response scale.

Analysis

Interviewers completed postinterview summaries for team debriefing and consensus building. Interviews were coded using a priori (from piloting evaluations and relevant literature) and emergent (refined and developed from data) codes. Deductive and inductive content analyses were conducted. ¹⁶ Deductive analysis used a priori categories (eg, care coordination, EHR training). Inductive content analysis consisted of open and unstructured coding, capturing data outside a priori categories. Emergent codes captured unidentified categories. Qualitative researchers met weekly to discuss data and reach consensus on interpretation.

Descriptive analysis was conducted using top-2 box scoring (proportion responding within the 2 most favorable responses [agree/ strongly agree]). Survey data were analyzed in SAS.¹⁷ The analysis used a merging approach on simultaneously collected qualitative and quantitative data to reach findings consensus.¹⁸

Researcher and research team decisions may shape the data collected due to prior assumptions and experience.¹⁹ This analysis attempted to integrate reflexivity practices to enhance awareness of the researchers’ assumptions and positionality, including by integrating intent collaborative conversing and memorandum writing into the processes.^20,21

Results

This analysis created a survey and fielded responses from HPTs present at FHCC across 3 time points (6 months prelaunch, 1 month prelaunch, and 2 months postlaunch), resulting in a total of 103 responses and an average response rate of 19.0% (Table 2). Six key findings were identified in analysis of responses: (1) critiques of transition management; (2) concerns with training; (3) hope about the EHR; (4) at-the-elbow support was essential; (5) HPTs adjusted to, and later preferred, the new EHR; and (6) transition impacted clinical training, but not overall career plans for HPTs. Findings are presented in this section, with illustrative quantitative data and qualitative data quotes available in the eAppendix.

Critiques of the Transition’s Management

While participants were aware of the transition to the new EHR, most felt they did not have enough information or time to prepare for it, indicating it was “too little, too late.” HPTs felt necessary workflow processes for Cerner/Oracle Health were not determined with enough time to learn them prior to transition. Supervisors shared that important workflow and onboarding decisions remained undecided mere weeks before the transition. Some service lines did not decrease patient loads until right before the transition, making it difficult to manage their schedules and resulting in insufficient time to learn the new EHR.

EHR Training Concerns

Overall, HPTs expressed low satisfaction with computer-based Training Management System (TMS) EHR training, believing it did not prepare them for the new EHR. The percentage of HPTs satisfied or very satisfied with the quality of TMS training was lower than that of instructor-based training pre- and posttransition, with 50% of 36 prelaunch respondents, and 43% of 29 postlaunch respondents expressing satisfaction with computer-based trainings (Figure 1). HPTs were dissatisfied with the training content. They felt it was too general and failed to teach basic tasks in the workflow for their service areas and roles, such as writing a note or order. Furthermore, poor content was exacerbated by poor and unengaging instruction, and HPTs were dissatisfied with the practice EHR used in training, which glitched frequently.

EHR Transition Optimism

Even though the transition was stressful, most HPTs hoped it would be a temporary disruption and that they would quickly adjust to the new EHR. Many participants expected that once they switched to the new EHR, they would pick it up quickly. In addition, many anticipated Cerner/Oracle Health would be better and easier to use in the long run.

At-The-Elbow Support Essential

VHA peer support with NESSU was highly valued among HPTs. NESSU staff were highly knowledgeable and could provide both broad and service-line-specific support. NESSU provided prompt answers to EHR questions. This was particularly critical as other forms of in-person support were often inaccessible or absent during the transition.

HPTs found facility support helpful: 85% of 36 respondents reported being satisfied/ very satisfied with support from supervisors and preceptors, and 84% of 36 respondents were satisfied/very satisfied with technical support from facility informatics staff pretransition (n = 36) (Figure 2). NESSU and supervisor support with daily workflows were particularly helpful, as pretransition training only provided a general introduction to the EHR.

HPTs Adjusted to and Later Preferred the New EHR

The EHR learning experience was intense but short, with many HPTs feeling able to use it only 2 to 4 weeks posttransition. Confidence grew as HPTs came to view Cerner/Oracle Health as a more integrated and intuitive system than the previous EHR. Most participants preferred the new EHR, even if they criticized some features (eg, no group documentation capabilities). Survey participants frequently rated Cerner/Oracle Health usability higher than the original. A total of 32% of 29 posttransition respondents agreed or strongly agreed that Cerner/Oracle Health helps prevent situations that can lead to patient safety risks—higher than pretransition rates. Additionally, fewer respondents found the new EHR unnecessarily complex or thought it contained too many alerts and flags compared to the original EHR (Figure 3).

Impact on Clinical Training, Not Career Plans

The extensive time and energy the transition demanded of HPTs caused stress and affected their clinical training. Many believed they would have learned more if their training had happened outside the transition.

Concerns that the transition affected learning were most acutely felt pretransition. HPTs reporting that EHR implementation positively affected their clinical education fell from 38% of 36 respondents 6 months pretransition to 19% of 29 respondents 1 month pretransition, but returned to 37% posttransition (Figure 4). However, some HPTs believed there was a silver lining: it provided a learning experience they otherwise would not have had.

HPTs who believed the transition positively impacted their likelihood of pursuing future career opportunities within the VHA rose to 33% of 29 respondents posttransition. Overall, Cerner/Oracle Health was characterized as a tool: something used in training, but not something that precluded wanting VHA careers or having meaningful experiences, such as caring for patients.

Discussion

This evaluation addressed an underexplored aspect of EHR transitions: their impact on HPTs. It identified HPT challenges, including dissatisfaction with poor transition preparation and EHR training experiences. Promising findings include positive experiences with transition support, EHR uptake, and overall positive educational experiences despite the transition’s disruption.

When EHR users, including HPTs, are dissatisfied with transition preparations, consequent stress can lead to undesired effects, including increased burnout, inappropriate EHR use, and low work satisfaction.^22-24 Negative EHR transition experiences shape HPTs’ subsequent EHR adoption, user satisfaction, as well as confidence and career intent.^3,25,26 Health systems have strong incentives to implement effective transition change management.

HPTs at previous VHA EHR transition sites reported significantly more disruption to their clinical training compared with HPTs at FHCC. Academic programs were shut down at the first transition site, and HPTs expressed decreased interest in VHA careers at another, even a year posttransition.^6,27 These findings are consistent with the limited literature on the adverse impacts that EHR transitions have on HPTs.^7,28

HPT retention is critical. VA is mandated to prepare the next generation of HPTs for its needs, and those of the nation. The VA relies heavily on HPT retention to recruit clinicians: > 65% of VHA physicians nationwide participated in VHA training programs prior to recruitment into staff positions.^5,29

VHA should invest in transition change management with demonstrated, positive impacts on HPTs, such as in-house support from clinicians. Previous research found that lack of support was a major source of stress and negative outcomes.^6,27 Consequently, supporting HPTs through EHR transitions directly contributes to the VHA’s ability to attract high-quality staff from its HPTs. The challenges and promising practices described in this analysis underscore the necessity of understanding how all EHR users are affected by transitions. What happens to them has direct implications for the VA mission to provide safe, efficient care, and its mandate to provide quality clinical training to HPTs.

These findings hold hopeful implications for supporting HPT EHR use, both during and outside EHR transitions. HPTs expressing that an EHR is only 1 part of their clinical training experience suggests that change management can improve EHR transitions. HPT learning can enhance known factors that are important for HPTs in clinical training, including the health care organization’s mission, caring for patients, and personal development.

Further investigations may engage HPTs at future VHA sites making the transition to the new EHR. One focus would involve applying a learning health systems framework to examine the nature of change management efforts—and their effects on HPT transition experiences—iteratively across transition sites to evaluate the effect of the efforts. Another focus may be longitudinal engagement with HPTs at health care systems and sites transitioning to new EHRs. Research has found that disruptions to EHR usability, satisfaction, and care provision can persist for 2 years and beyond following an EHR transition.³⁰ Evaluating the long-term effects of transitions on HPTs is of interest, given their distinct characteristics and differences from employees.

Limitations

Study data came from voluntary participants at 1 highly engaged site, raising the possibility of self-selection bias. HPT experiences at other VA and non-VA sites may differ. Employees and HPTs were engaged during a high-stress event; snowballing recruitment reach was limited by high workloads and limited time for engagement. Statistical data were descriptive and should not be interpreted as causal. Results may reflect, in part, temporal effects, and respondents include HPTs at different stages of training and with different levels of VA experience. Survey sample sizes may limit generalizability; however, merging data streams strengthened the reliability of findings.

Conclusions

The results of this analysis of FHCC HPTs were notably more positive than those of HPTs at previous VHA EHR transition sites. VHA is one of many health care systems that provide clinical training for HPTs and relies on this population to provide patient care. By highlighting challenges and positive experiences of HPTs during an EHR transition, this evaluation produces actionable insights that can inform the actions of health care systems seeking to support HPTs during disruptive EHR transitions.

The Veterans Health Administration (VHA) is transitioning from its native electronic health record (EHR) Vista/Computerized Patient Record System to the commercial Cerner/Oracle Health EHR. Though this process was temporarily discontinued in April 2023 due to patient safety, usability, and reliability concerns, it resumed in April 2026. It was originally projected to cost $50 billion to implement. ^1-3 As of March 9, 2024, 6 sites had transitioned to the new EHR.² The transition is the largest of its kind in the US, offering an unparalleled opportunity to examine the effects of EHR transitions on an often overlooked part of the workforce: health professions trainees (HPTs).

HPTs serve a central role in VHA. About one-third of patients receive care directly from HPTs who make up about one-third of the VHA workforce. VHA trains > 60 clinical disciplines, comprising > 122,000 trainees annually.^4,5 A paucity of literature exists exploring the experiences of HPTs during EHR transitions, and many studies are often limited to single-site or small populations. HPTs face distinct challenges and needs during EHR transitions and are particularly vulnerable to their negative impacts on retention, clinical training, and efficiency and confidence in EHR use.^6-10 HPTs at VHA sites that have already transitioned to the Cerner/Oracle Health EHR identified many challenges, including significant delays in gaining EHR access, pervasive perceptions of poor training, concerns that EHR functionality issues limited patient care, and decreased ability to track clinical skill acquisition.⁶ These challenges may impact some HPTs more than others (eg, students on short rotations are affected more acutely by delayed EHR access and usage).

This quality improvement project evaluated HPT EHR transition experiences at the Captain James A. Lovell Federal Health Care Center (FHCC). This article contributes to the limited literature on HPT transition experiences, identifies opportunities to support HPTs, and informs broader efforts in teaching HPTs new technologies.

Methods

FHCC is jointly operated by the US Department of Defense and US Department of Veterans Affairs (VA). It treats 80,000 inpatient and outpatients annually. FHCC was the sixth VA facility to transition to the new EHR, which went live on March 9, 2024.^2,11 About 700 HPTs rotate through FHCC annually. HPTs were eligible for inclusion if they were present during the March 9 transition according to a VA Office of Academic Affiliations database. A total of 216 HPTs were identified for inclusion.

Preparations for the transition included scaling down operations (ie, blocking clinician schedules, not scheduling future appointments that may conflict with the transition, making decisions on new facility- and service-line workflows, required EHR training, and speaking with support staff, including VHA National EHR Modernization Supplemental Staffing Unit [NESSU]). This evaluation was designated nonresearch/quality improvement by the VA Bedford Healthcare System Institutional Review Board.

Surveys

Forty-seven interviews were conducted with HPTs, site leaders, and supervisors from January 2024 to June 2024 (Table 1). Participants were identified by service leads and recruited via email; snowball sampling identified additional participants.

The evaluation team developed semistructured interview guides using grounded probes based on a pilot evaluation and existing research on EHR transitions.¹² Questions focused on participant experiences preparing for the EHR transition, learning and using the site’s EHR, and the impact the transition had on clinical training experiences. Interviews were conducted at different times to capture the range of user experiences: 1 month prelaunch, 2 to 6 weeks postlaunch, and 2 months postlaunch. Interviewees were informed of participant rights and provided verbal consent.

HPTs present at FHCC at each survey’s release were emailed invitations and 2 reminders. The anonymous surveys took about 10 minutes to complete. Survey items queried HPTs about their experiences preparing to use the new EHR, perceptions of the current EHR (adapted from the System Usability Scale), satisfaction with VHA training, impact on clinical training, ability to work with preceptors and patients, and experiences with the VHA clinical learning environment (adapted from the VHA Learners Preceptor Survey).^13-15 Survey questions used a 5-point Likert response scale.

Analysis

Interviewers completed postinterview summaries for team debriefing and consensus building. Interviews were coded using a priori (from piloting evaluations and relevant literature) and emergent (refined and developed from data) codes. Deductive and inductive content analyses were conducted. ¹⁶ Deductive analysis used a priori categories (eg, care coordination, EHR training). Inductive content analysis consisted of open and unstructured coding, capturing data outside a priori categories. Emergent codes captured unidentified categories. Qualitative researchers met weekly to discuss data and reach consensus on interpretation.

Descriptive analysis was conducted using top-2 box scoring (proportion responding within the 2 most favorable responses [agree/ strongly agree]). Survey data were analyzed in SAS.¹⁷ The analysis used a merging approach on simultaneously collected qualitative and quantitative data to reach findings consensus.¹⁸

Researcher and research team decisions may shape the data collected due to prior assumptions and experience.¹⁹ This analysis attempted to integrate reflexivity practices to enhance awareness of the researchers’ assumptions and positionality, including by integrating intent collaborative conversing and memorandum writing into the processes.^20,21

Results

This analysis created a survey and fielded responses from HPTs present at FHCC across 3 time points (6 months prelaunch, 1 month prelaunch, and 2 months postlaunch), resulting in a total of 103 responses and an average response rate of 19.0% (Table 2). Six key findings were identified in analysis of responses: (1) critiques of transition management; (2) concerns with training; (3) hope about the EHR; (4) at-the-elbow support was essential; (5) HPTs adjusted to, and later preferred, the new EHR; and (6) transition impacted clinical training, but not overall career plans for HPTs. Findings are presented in this section, with illustrative quantitative data and qualitative data quotes available in the eAppendix.

Critiques of the Transition’s Management

While participants were aware of the transition to the new EHR, most felt they did not have enough information or time to prepare for it, indicating it was “too little, too late.” HPTs felt necessary workflow processes for Cerner/Oracle Health were not determined with enough time to learn them prior to transition. Supervisors shared that important workflow and onboarding decisions remained undecided mere weeks before the transition. Some service lines did not decrease patient loads until right before the transition, making it difficult to manage their schedules and resulting in insufficient time to learn the new EHR.

EHR Training Concerns

Overall, HPTs expressed low satisfaction with computer-based Training Management System (TMS) EHR training, believing it did not prepare them for the new EHR. The percentage of HPTs satisfied or very satisfied with the quality of TMS training was lower than that of instructor-based training pre- and posttransition, with 50% of 36 prelaunch respondents, and 43% of 29 postlaunch respondents expressing satisfaction with computer-based trainings (Figure 1). HPTs were dissatisfied with the training content. They felt it was too general and failed to teach basic tasks in the workflow for their service areas and roles, such as writing a note or order. Furthermore, poor content was exacerbated by poor and unengaging instruction, and HPTs were dissatisfied with the practice EHR used in training, which glitched frequently.

EHR Transition Optimism

Even though the transition was stressful, most HPTs hoped it would be a temporary disruption and that they would quickly adjust to the new EHR. Many participants expected that once they switched to the new EHR, they would pick it up quickly. In addition, many anticipated Cerner/Oracle Health would be better and easier to use in the long run.

At-The-Elbow Support Essential

VHA peer support with NESSU was highly valued among HPTs. NESSU staff were highly knowledgeable and could provide both broad and service-line-specific support. NESSU provided prompt answers to EHR questions. This was particularly critical as other forms of in-person support were often inaccessible or absent during the transition.

HPTs found facility support helpful: 85% of 36 respondents reported being satisfied/ very satisfied with support from supervisors and preceptors, and 84% of 36 respondents were satisfied/very satisfied with technical support from facility informatics staff pretransition (n = 36) (Figure 2). NESSU and supervisor support with daily workflows were particularly helpful, as pretransition training only provided a general introduction to the EHR.

HPTs Adjusted to and Later Preferred the New EHR

The EHR learning experience was intense but short, with many HPTs feeling able to use it only 2 to 4 weeks posttransition. Confidence grew as HPTs came to view Cerner/Oracle Health as a more integrated and intuitive system than the previous EHR. Most participants preferred the new EHR, even if they criticized some features (eg, no group documentation capabilities). Survey participants frequently rated Cerner/Oracle Health usability higher than the original. A total of 32% of 29 posttransition respondents agreed or strongly agreed that Cerner/Oracle Health helps prevent situations that can lead to patient safety risks—higher than pretransition rates. Additionally, fewer respondents found the new EHR unnecessarily complex or thought it contained too many alerts and flags compared to the original EHR (Figure 3).

Impact on Clinical Training, Not Career Plans

The extensive time and energy the transition demanded of HPTs caused stress and affected their clinical training. Many believed they would have learned more if their training had happened outside the transition.

Concerns that the transition affected learning were most acutely felt pretransition. HPTs reporting that EHR implementation positively affected their clinical education fell from 38% of 36 respondents 6 months pretransition to 19% of 29 respondents 1 month pretransition, but returned to 37% posttransition (Figure 4). However, some HPTs believed there was a silver lining: it provided a learning experience they otherwise would not have had.

HPTs who believed the transition positively impacted their likelihood of pursuing future career opportunities within the VHA rose to 33% of 29 respondents posttransition. Overall, Cerner/Oracle Health was characterized as a tool: something used in training, but not something that precluded wanting VHA careers or having meaningful experiences, such as caring for patients.

Discussion

This evaluation addressed an underexplored aspect of EHR transitions: their impact on HPTs. It identified HPT challenges, including dissatisfaction with poor transition preparation and EHR training experiences. Promising findings include positive experiences with transition support, EHR uptake, and overall positive educational experiences despite the transition’s disruption.

When EHR users, including HPTs, are dissatisfied with transition preparations, consequent stress can lead to undesired effects, including increased burnout, inappropriate EHR use, and low work satisfaction.^22-24 Negative EHR transition experiences shape HPTs’ subsequent EHR adoption, user satisfaction, as well as confidence and career intent.^3,25,26 Health systems have strong incentives to implement effective transition change management.

HPTs at previous VHA EHR transition sites reported significantly more disruption to their clinical training compared with HPTs at FHCC. Academic programs were shut down at the first transition site, and HPTs expressed decreased interest in VHA careers at another, even a year posttransition.^6,27 These findings are consistent with the limited literature on the adverse impacts that EHR transitions have on HPTs.^7,28

HPT retention is critical. VA is mandated to prepare the next generation of HPTs for its needs, and those of the nation. The VA relies heavily on HPT retention to recruit clinicians: > 65% of VHA physicians nationwide participated in VHA training programs prior to recruitment into staff positions.^5,29

VHA should invest in transition change management with demonstrated, positive impacts on HPTs, such as in-house support from clinicians. Previous research found that lack of support was a major source of stress and negative outcomes.^6,27 Consequently, supporting HPTs through EHR transitions directly contributes to the VHA’s ability to attract high-quality staff from its HPTs. The challenges and promising practices described in this analysis underscore the necessity of understanding how all EHR users are affected by transitions. What happens to them has direct implications for the VA mission to provide safe, efficient care, and its mandate to provide quality clinical training to HPTs.

These findings hold hopeful implications for supporting HPT EHR use, both during and outside EHR transitions. HPTs expressing that an EHR is only 1 part of their clinical training experience suggests that change management can improve EHR transitions. HPT learning can enhance known factors that are important for HPTs in clinical training, including the health care organization’s mission, caring for patients, and personal development.

Further investigations may engage HPTs at future VHA sites making the transition to the new EHR. One focus would involve applying a learning health systems framework to examine the nature of change management efforts—and their effects on HPT transition experiences—iteratively across transition sites to evaluate the effect of the efforts. Another focus may be longitudinal engagement with HPTs at health care systems and sites transitioning to new EHRs. Research has found that disruptions to EHR usability, satisfaction, and care provision can persist for 2 years and beyond following an EHR transition.³⁰ Evaluating the long-term effects of transitions on HPTs is of interest, given their distinct characteristics and differences from employees.

Limitations

Study data came from voluntary participants at 1 highly engaged site, raising the possibility of self-selection bias. HPT experiences at other VA and non-VA sites may differ. Employees and HPTs were engaged during a high-stress event; snowballing recruitment reach was limited by high workloads and limited time for engagement. Statistical data were descriptive and should not be interpreted as causal. Results may reflect, in part, temporal effects, and respondents include HPTs at different stages of training and with different levels of VA experience. Survey sample sizes may limit generalizability; however, merging data streams strengthened the reliability of findings.

Conclusions

The results of this analysis of FHCC HPTs were notably more positive than those of HPTs at previous VHA EHR transition sites. VHA is one of many health care systems that provide clinical training for HPTs and relies on this population to provide patient care. By highlighting challenges and positive experiences of HPTs during an EHR transition, this evaluation produces actionable insights that can inform the actions of health care systems seeking to support HPTs during disruptive EHR transitions.

The Veterans Health Administration (VHA) is transitioning from its native electronic health record (EHR) Vista/Computerized Patient Record System to the commercial Cerner/Oracle Health EHR. Though this process was temporarily discontinued in April 2023 due to patient safety, usability, and reliability concerns, it resumed in April 2026. It was originally projected to cost $50 billion to implement. ^1-3 As of March 9, 2024, 6 sites had transitioned to the new EHR.² The transition is the largest of its kind in the US, offering an unparalleled opportunity to examine the effects of EHR transitions on an often overlooked part of the workforce: health professions trainees (HPTs).

HPTs serve a central role in VHA. About one-third of patients receive care directly from HPTs who make up about one-third of the VHA workforce. VHA trains > 60 clinical disciplines, comprising > 122,000 trainees annually.^4,5 A paucity of literature exists exploring the experiences of HPTs during EHR transitions, and many studies are often limited to single-site or small populations. HPTs face distinct challenges and needs during EHR transitions and are particularly vulnerable to their negative impacts on retention, clinical training, and efficiency and confidence in EHR use.^6-10 HPTs at VHA sites that have already transitioned to the Cerner/Oracle Health EHR identified many challenges, including significant delays in gaining EHR access, pervasive perceptions of poor training, concerns that EHR functionality issues limited patient care, and decreased ability to track clinical skill acquisition.⁶ These challenges may impact some HPTs more than others (eg, students on short rotations are affected more acutely by delayed EHR access and usage).

This quality improvement project evaluated HPT EHR transition experiences at the Captain James A. Lovell Federal Health Care Center (FHCC). This article contributes to the limited literature on HPT transition experiences, identifies opportunities to support HPTs, and informs broader efforts in teaching HPTs new technologies.

Methods

FHCC is jointly operated by the US Department of Defense and US Department of Veterans Affairs (VA). It treats 80,000 inpatient and outpatients annually. FHCC was the sixth VA facility to transition to the new EHR, which went live on March 9, 2024.^2,11 About 700 HPTs rotate through FHCC annually. HPTs were eligible for inclusion if they were present during the March 9 transition according to a VA Office of Academic Affiliations database. A total of 216 HPTs were identified for inclusion.

Preparations for the transition included scaling down operations (ie, blocking clinician schedules, not scheduling future appointments that may conflict with the transition, making decisions on new facility- and service-line workflows, required EHR training, and speaking with support staff, including VHA National EHR Modernization Supplemental Staffing Unit [NESSU]). This evaluation was designated nonresearch/quality improvement by the VA Bedford Healthcare System Institutional Review Board.

Surveys

Forty-seven interviews were conducted with HPTs, site leaders, and supervisors from January 2024 to June 2024 (Table 1). Participants were identified by service leads and recruited via email; snowball sampling identified additional participants.

The evaluation team developed semistructured interview guides using grounded probes based on a pilot evaluation and existing research on EHR transitions.¹² Questions focused on participant experiences preparing for the EHR transition, learning and using the site’s EHR, and the impact the transition had on clinical training experiences. Interviews were conducted at different times to capture the range of user experiences: 1 month prelaunch, 2 to 6 weeks postlaunch, and 2 months postlaunch. Interviewees were informed of participant rights and provided verbal consent.

HPTs present at FHCC at each survey’s release were emailed invitations and 2 reminders. The anonymous surveys took about 10 minutes to complete. Survey items queried HPTs about their experiences preparing to use the new EHR, perceptions of the current EHR (adapted from the System Usability Scale), satisfaction with VHA training, impact on clinical training, ability to work with preceptors and patients, and experiences with the VHA clinical learning environment (adapted from the VHA Learners Preceptor Survey).^13-15 Survey questions used a 5-point Likert response scale.

Analysis

Interviewers completed postinterview summaries for team debriefing and consensus building. Interviews were coded using a priori (from piloting evaluations and relevant literature) and emergent (refined and developed from data) codes. Deductive and inductive content analyses were conducted. ¹⁶ Deductive analysis used a priori categories (eg, care coordination, EHR training). Inductive content analysis consisted of open and unstructured coding, capturing data outside a priori categories. Emergent codes captured unidentified categories. Qualitative researchers met weekly to discuss data and reach consensus on interpretation.

Descriptive analysis was conducted using top-2 box scoring (proportion responding within the 2 most favorable responses [agree/ strongly agree]). Survey data were analyzed in SAS.¹⁷ The analysis used a merging approach on simultaneously collected qualitative and quantitative data to reach findings consensus.¹⁸

Researcher and research team decisions may shape the data collected due to prior assumptions and experience.¹⁹ This analysis attempted to integrate reflexivity practices to enhance awareness of the researchers’ assumptions and positionality, including by integrating intent collaborative conversing and memorandum writing into the processes.^20,21

Results

This analysis created a survey and fielded responses from HPTs present at FHCC across 3 time points (6 months prelaunch, 1 month prelaunch, and 2 months postlaunch), resulting in a total of 103 responses and an average response rate of 19.0% (Table 2). Six key findings were identified in analysis of responses: (1) critiques of transition management; (2) concerns with training; (3) hope about the EHR; (4) at-the-elbow support was essential; (5) HPTs adjusted to, and later preferred, the new EHR; and (6) transition impacted clinical training, but not overall career plans for HPTs. Findings are presented in this section, with illustrative quantitative data and qualitative data quotes available in the eAppendix.

Critiques of the Transition’s Management

While participants were aware of the transition to the new EHR, most felt they did not have enough information or time to prepare for it, indicating it was “too little, too late.” HPTs felt necessary workflow processes for Cerner/Oracle Health were not determined with enough time to learn them prior to transition. Supervisors shared that important workflow and onboarding decisions remained undecided mere weeks before the transition. Some service lines did not decrease patient loads until right before the transition, making it difficult to manage their schedules and resulting in insufficient time to learn the new EHR.

EHR Training Concerns

Overall, HPTs expressed low satisfaction with computer-based Training Management System (TMS) EHR training, believing it did not prepare them for the new EHR. The percentage of HPTs satisfied or very satisfied with the quality of TMS training was lower than that of instructor-based training pre- and posttransition, with 50% of 36 prelaunch respondents, and 43% of 29 postlaunch respondents expressing satisfaction with computer-based trainings (Figure 1). HPTs were dissatisfied with the training content. They felt it was too general and failed to teach basic tasks in the workflow for their service areas and roles, such as writing a note or order. Furthermore, poor content was exacerbated by poor and unengaging instruction, and HPTs were dissatisfied with the practice EHR used in training, which glitched frequently.

EHR Transition Optimism

Even though the transition was stressful, most HPTs hoped it would be a temporary disruption and that they would quickly adjust to the new EHR. Many participants expected that once they switched to the new EHR, they would pick it up quickly. In addition, many anticipated Cerner/Oracle Health would be better and easier to use in the long run.

At-The-Elbow Support Essential

VHA peer support with NESSU was highly valued among HPTs. NESSU staff were highly knowledgeable and could provide both broad and service-line-specific support. NESSU provided prompt answers to EHR questions. This was particularly critical as other forms of in-person support were often inaccessible or absent during the transition.

HPTs found facility support helpful: 85% of 36 respondents reported being satisfied/ very satisfied with support from supervisors and preceptors, and 84% of 36 respondents were satisfied/very satisfied with technical support from facility informatics staff pretransition (n = 36) (Figure 2). NESSU and supervisor support with daily workflows were particularly helpful, as pretransition training only provided a general introduction to the EHR.

HPTs Adjusted to and Later Preferred the New EHR

The EHR learning experience was intense but short, with many HPTs feeling able to use it only 2 to 4 weeks posttransition. Confidence grew as HPTs came to view Cerner/Oracle Health as a more integrated and intuitive system than the previous EHR. Most participants preferred the new EHR, even if they criticized some features (eg, no group documentation capabilities). Survey participants frequently rated Cerner/Oracle Health usability higher than the original. A total of 32% of 29 posttransition respondents agreed or strongly agreed that Cerner/Oracle Health helps prevent situations that can lead to patient safety risks—higher than pretransition rates. Additionally, fewer respondents found the new EHR unnecessarily complex or thought it contained too many alerts and flags compared to the original EHR (Figure 3).

Impact on Clinical Training, Not Career Plans

The extensive time and energy the transition demanded of HPTs caused stress and affected their clinical training. Many believed they would have learned more if their training had happened outside the transition.

Concerns that the transition affected learning were most acutely felt pretransition. HPTs reporting that EHR implementation positively affected their clinical education fell from 38% of 36 respondents 6 months pretransition to 19% of 29 respondents 1 month pretransition, but returned to 37% posttransition (Figure 4). However, some HPTs believed there was a silver lining: it provided a learning experience they otherwise would not have had.

HPTs who believed the transition positively impacted their likelihood of pursuing future career opportunities within the VHA rose to 33% of 29 respondents posttransition. Overall, Cerner/Oracle Health was characterized as a tool: something used in training, but not something that precluded wanting VHA careers or having meaningful experiences, such as caring for patients.

Discussion

This evaluation addressed an underexplored aspect of EHR transitions: their impact on HPTs. It identified HPT challenges, including dissatisfaction with poor transition preparation and EHR training experiences. Promising findings include positive experiences with transition support, EHR uptake, and overall positive educational experiences despite the transition’s disruption.

When EHR users, including HPTs, are dissatisfied with transition preparations, consequent stress can lead to undesired effects, including increased burnout, inappropriate EHR use, and low work satisfaction.^22-24 Negative EHR transition experiences shape HPTs’ subsequent EHR adoption, user satisfaction, as well as confidence and career intent.^3,25,26 Health systems have strong incentives to implement effective transition change management.

HPTs at previous VHA EHR transition sites reported significantly more disruption to their clinical training compared with HPTs at FHCC. Academic programs were shut down at the first transition site, and HPTs expressed decreased interest in VHA careers at another, even a year posttransition.^6,27 These findings are consistent with the limited literature on the adverse impacts that EHR transitions have on HPTs.^7,28

HPT retention is critical. VA is mandated to prepare the next generation of HPTs for its needs, and those of the nation. The VA relies heavily on HPT retention to recruit clinicians: > 65% of VHA physicians nationwide participated in VHA training programs prior to recruitment into staff positions.^5,29

VHA should invest in transition change management with demonstrated, positive impacts on HPTs, such as in-house support from clinicians. Previous research found that lack of support was a major source of stress and negative outcomes.^6,27 Consequently, supporting HPTs through EHR transitions directly contributes to the VHA’s ability to attract high-quality staff from its HPTs. The challenges and promising practices described in this analysis underscore the necessity of understanding how all EHR users are affected by transitions. What happens to them has direct implications for the VA mission to provide safe, efficient care, and its mandate to provide quality clinical training to HPTs.

These findings hold hopeful implications for supporting HPT EHR use, both during and outside EHR transitions. HPTs expressing that an EHR is only 1 part of their clinical training experience suggests that change management can improve EHR transitions. HPT learning can enhance known factors that are important for HPTs in clinical training, including the health care organization’s mission, caring for patients, and personal development.

Further investigations may engage HPTs at future VHA sites making the transition to the new EHR. One focus would involve applying a learning health systems framework to examine the nature of change management efforts—and their effects on HPT transition experiences—iteratively across transition sites to evaluate the effect of the efforts. Another focus may be longitudinal engagement with HPTs at health care systems and sites transitioning to new EHRs. Research has found that disruptions to EHR usability, satisfaction, and care provision can persist for 2 years and beyond following an EHR transition.³⁰ Evaluating the long-term effects of transitions on HPTs is of interest, given their distinct characteristics and differences from employees.

Limitations

Study data came from voluntary participants at 1 highly engaged site, raising the possibility of self-selection bias. HPT experiences at other VA and non-VA sites may differ. Employees and HPTs were engaged during a high-stress event; snowballing recruitment reach was limited by high workloads and limited time for engagement. Statistical data were descriptive and should not be interpreted as causal. Results may reflect, in part, temporal effects, and respondents include HPTs at different stages of training and with different levels of VA experience. Survey sample sizes may limit generalizability; however, merging data streams strengthened the reliability of findings.

Conclusions

The results of this analysis of FHCC HPTs were notably more positive than those of HPTs at previous VHA EHR transition sites. VHA is one of many health care systems that provide clinical training for HPTs and relies on this population to provide patient care. By highlighting challenges and positive experiences of HPTs during an EHR transition, this evaluation produces actionable insights that can inform the actions of health care systems seeking to support HPTs during disruptive EHR transitions.

The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.

Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.

However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.

As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.

Where we stand January 2017

Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.

“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”

In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.¹ The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.² Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.³ However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”

Key provisions: A delicate balance

Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.

“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”

Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.

And … Medicare

The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.

“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”

Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.¹ Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.

“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”

Seniors may also find themselves rationing or skimping on care.

Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.⁶

MACRA launch

Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.

“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”

Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”

On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.

“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”

Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.

Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.

“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”

At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.

“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”

He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.” 

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.

2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.

3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.

4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.

5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.

6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.

The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.

Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.

However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.

As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.

Where we stand January 2017

Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.

“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”

In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.¹ The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.² Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.³ However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”

Key provisions: A delicate balance

Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.

“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”

Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.

And … Medicare

The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.

“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”

Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.¹ Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.

“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”

Seniors may also find themselves rationing or skimping on care.

Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.⁶

MACRA launch

Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.

“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”

Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”

On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.

“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”

Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.

Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.

“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”

At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.

“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”

He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.” 

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.

2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.

3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.

4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.

5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.

6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.

The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.

Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.

However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.

As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.

Where we stand January 2017

Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.

“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”

In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.¹ The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.² Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.³ However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”

Key provisions: A delicate balance

Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.

“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”

Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.

And … Medicare

The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.

“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”

Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.¹ Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.

“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”

Seniors may also find themselves rationing or skimping on care.

Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.⁶

MACRA launch

Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.

“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”

Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”

On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.

“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”

Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.

Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.

“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”

At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.

“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”

He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.” 

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.

2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.

3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.

4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.

5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.

6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.

Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.

Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.

Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.

The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.

Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.

The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.

However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.

Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.

"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.

Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.

Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.

The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.

Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.

Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.

Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.

The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.

Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.

The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.

However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.

Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.

"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.

Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.

Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.

The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.

Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.

Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.

Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.

The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.

Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.

The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.

However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.

Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.

"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.

Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.

Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.

The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.

“We are missing an important opportunity to learn from what is going on in health systems every day that could tell us how to make healthcare better and cheaper,” says Dr. Fisher, lead author of a January 2016 JAMA “Viewpoint” called “Implementation Science: A Potential Catalyst for Delivery System Reform.” “That’s the argument for the the field of implementation science.”

Implementation science studies ways to promote the integration of research findings and evidence into the healthcare system. Dr. Fisher says that integration is influenced by multiple factors: the characteristic of the innovation itself, the organizational setting, and the policy or community environment within which that organization is working. Context matters.

“We tend to think about adopting innovations like a new blood pressure medication or a new device,” Dr. Fisher says. “Those decisions rest almost entirely on the shoulders of physicians, so adoption requires thinking about the attributes of biomedical innovations and how physicians think.”

With care delivery innovations—for example, how to provide optimal care for people with heart failure across home, hospital, and nursing home—those are often developed with clinical input but by people who are fundamentally managers.

“It’s a more complex set of actors,” he says, “so you have to think about those decision makers if you’re going to get the best evidence-based practice into their setting.”

A third category of innovation focuses on individual behavior change, where the decision makers are the clinician and the patient and family. “You’ve got to persuade the patient the innovation is worth doing, so different factors may influence the successful adoptions of those interventions,” Dr. Fisher says.

Reference

1. Fisher ES, Shortell SM, Savitz LA. Implementation science: a potential catalyst for delivery system reform. JAMA. 2016;315(4):339-340. doi:10.1001/jama.2015.17949.

“We are missing an important opportunity to learn from what is going on in health systems every day that could tell us how to make healthcare better and cheaper,” says Dr. Fisher, lead author of a January 2016 JAMA “Viewpoint” called “Implementation Science: A Potential Catalyst for Delivery System Reform.” “That’s the argument for the the field of implementation science.”

Implementation science studies ways to promote the integration of research findings and evidence into the healthcare system. Dr. Fisher says that integration is influenced by multiple factors: the characteristic of the innovation itself, the organizational setting, and the policy or community environment within which that organization is working. Context matters.

“We tend to think about adopting innovations like a new blood pressure medication or a new device,” Dr. Fisher says. “Those decisions rest almost entirely on the shoulders of physicians, so adoption requires thinking about the attributes of biomedical innovations and how physicians think.”

With care delivery innovations—for example, how to provide optimal care for people with heart failure across home, hospital, and nursing home—those are often developed with clinical input but by people who are fundamentally managers.

“It’s a more complex set of actors,” he says, “so you have to think about those decision makers if you’re going to get the best evidence-based practice into their setting.”

A third category of innovation focuses on individual behavior change, where the decision makers are the clinician and the patient and family. “You’ve got to persuade the patient the innovation is worth doing, so different factors may influence the successful adoptions of those interventions,” Dr. Fisher says.

Reference

1. Fisher ES, Shortell SM, Savitz LA. Implementation science: a potential catalyst for delivery system reform. JAMA. 2016;315(4):339-340. doi:10.1001/jama.2015.17949.

“We are missing an important opportunity to learn from what is going on in health systems every day that could tell us how to make healthcare better and cheaper,” says Dr. Fisher, lead author of a January 2016 JAMA “Viewpoint” called “Implementation Science: A Potential Catalyst for Delivery System Reform.” “That’s the argument for the the field of implementation science.”

Implementation science studies ways to promote the integration of research findings and evidence into the healthcare system. Dr. Fisher says that integration is influenced by multiple factors: the characteristic of the innovation itself, the organizational setting, and the policy or community environment within which that organization is working. Context matters.

“We tend to think about adopting innovations like a new blood pressure medication or a new device,” Dr. Fisher says. “Those decisions rest almost entirely on the shoulders of physicians, so adoption requires thinking about the attributes of biomedical innovations and how physicians think.”

With care delivery innovations—for example, how to provide optimal care for people with heart failure across home, hospital, and nursing home—those are often developed with clinical input but by people who are fundamentally managers.

“It’s a more complex set of actors,” he says, “so you have to think about those decision makers if you’re going to get the best evidence-based practice into their setting.”

A third category of innovation focuses on individual behavior change, where the decision makers are the clinician and the patient and family. “You’ve got to persuade the patient the innovation is worth doing, so different factors may influence the successful adoptions of those interventions,” Dr. Fisher says.

Reference

1. Fisher ES, Shortell SM, Savitz LA. Implementation science: a potential catalyst for delivery system reform. JAMA. 2016;315(4):339-340. doi:10.1001/jama.2015.17949.

CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.

CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.

CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.

Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?

Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.

An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.

“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”

Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.

“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.

There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.

“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.

Larry Beresford is a freelance writer in Alameda, Calif.

Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?

Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.

An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.

“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”

Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.

“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.

There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.

“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.

Larry Beresford is a freelance writer in Alameda, Calif.

Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?

Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.

An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.

“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”

Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.

“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.

There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.

“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.

Larry Beresford is a freelance writer in Alameda, Calif.

Summary: The panel of high-tech doctors helped a standing-room-only crowd navigate numerous apps to be used at point-of-care [PDF, 458 kb]. Groups worked through case studies utilizing applicable mobile apps. Examples and most useful apps, including occasional user reviews, follow:

Provider-to-Provider Communication, HIPAA secure

• Doximity.
• HIPAA-chat.
• Pros: HIPAA-secure, real-time communication.
• Cons: Both parties must be on app to securely communicate.

Provider-to-Patient Communication, Language Translators

• Google Translate: multiple platforms, free, 90 languages.
• MediBabble: iOS only, free, seven languages, dedicated medical application.

Diagnostic Apps for Providers

• Calculate by QxM.
• PreOpEval14: iOS only.
• PreopRisk Assessment: Android only.
• ASCVD Risk Estimator.
• MDCalc.com in addition to usual formulas, great abg-analyzer (online version only).
• AnticoagEvaluator.
• epocrates: calculators.

Click here for a PDF of useful apps and resource links  [PDF, 177 kb]

Resources for Evidence-Based Practice

• ACP Clinical Guidelines.
• ACP Smart Medicine.
• Read by QxMD.
• UpToDate.
• AHRQ ePPS: identifies clinical preventive services.
• epocrates.

Patient Engagement Apps

• Medication reminders: MediSafe, CareZone.
• Pharmaceutical costs: Walmart, Target Healthful, GoodRx.
• Proper inhaler usage: User Inhalers App.
• Smoking cessation: QuitSTART.

HM15 takeaways

• Apps are available to providers and patients to enhance quality, value, and compliance;
• Before “prescribing” any app to patients, vet the application yourself; and
• Use apps to supplement your clinical practice, but be wary of becoming over-reliant upon them, to the detriment of long-term memory. In order to utilize information in critical-thinking processes, it must be stored in long-term memory. TH

Summary: The panel of high-tech doctors helped a standing-room-only crowd navigate numerous apps to be used at point-of-care [PDF, 458 kb]. Groups worked through case studies utilizing applicable mobile apps. Examples and most useful apps, including occasional user reviews, follow:

Provider-to-Provider Communication, HIPAA secure

• Doximity.
• HIPAA-chat.
• Pros: HIPAA-secure, real-time communication.
• Cons: Both parties must be on app to securely communicate.

Provider-to-Patient Communication, Language Translators

• Google Translate: multiple platforms, free, 90 languages.
• MediBabble: iOS only, free, seven languages, dedicated medical application.

Diagnostic Apps for Providers

• Calculate by QxM.
• PreOpEval14: iOS only.
• PreopRisk Assessment: Android only.
• ASCVD Risk Estimator.
• MDCalc.com in addition to usual formulas, great abg-analyzer (online version only).
• AnticoagEvaluator.
• epocrates: calculators.

Click here for a PDF of useful apps and resource links  [PDF, 177 kb]

Resources for Evidence-Based Practice

• ACP Clinical Guidelines.
• ACP Smart Medicine.
• Read by QxMD.
• UpToDate.
• AHRQ ePPS: identifies clinical preventive services.
• epocrates.

Patient Engagement Apps

• Medication reminders: MediSafe, CareZone.
• Pharmaceutical costs: Walmart, Target Healthful, GoodRx.
• Proper inhaler usage: User Inhalers App.
• Smoking cessation: QuitSTART.

HM15 takeaways

• Apps are available to providers and patients to enhance quality, value, and compliance;
• Before “prescribing” any app to patients, vet the application yourself; and
• Use apps to supplement your clinical practice, but be wary of becoming over-reliant upon them, to the detriment of long-term memory. In order to utilize information in critical-thinking processes, it must be stored in long-term memory. TH

Summary: The panel of high-tech doctors helped a standing-room-only crowd navigate numerous apps to be used at point-of-care [PDF, 458 kb]. Groups worked through case studies utilizing applicable mobile apps. Examples and most useful apps, including occasional user reviews, follow:

Provider-to-Provider Communication, HIPAA secure

• Doximity.
• HIPAA-chat.
• Pros: HIPAA-secure, real-time communication.
• Cons: Both parties must be on app to securely communicate.

Provider-to-Patient Communication, Language Translators

• Google Translate: multiple platforms, free, 90 languages.
• MediBabble: iOS only, free, seven languages, dedicated medical application.

Diagnostic Apps for Providers

• Calculate by QxM.
• PreOpEval14: iOS only.
• PreopRisk Assessment: Android only.
• ASCVD Risk Estimator.
• MDCalc.com in addition to usual formulas, great abg-analyzer (online version only).
• AnticoagEvaluator.
• epocrates: calculators.

Click here for a PDF of useful apps and resource links  [PDF, 177 kb]

Resources for Evidence-Based Practice

• ACP Clinical Guidelines.
• ACP Smart Medicine.
• Read by QxMD.
• UpToDate.
• AHRQ ePPS: identifies clinical preventive services.
• epocrates.

Patient Engagement Apps

• Medication reminders: MediSafe, CareZone.
• Pharmaceutical costs: Walmart, Target Healthful, GoodRx.
• Proper inhaler usage: User Inhalers App.
• Smoking cessation: QuitSTART.

HM15 takeaways

• Apps are available to providers and patients to enhance quality, value, and compliance;
• Before “prescribing” any app to patients, vet the application yourself; and
• Use apps to supplement your clinical practice, but be wary of becoming over-reliant upon them, to the detriment of long-term memory. In order to utilize information in critical-thinking processes, it must be stored in long-term memory. TH

Day Four highlights from HM15, the Society of Hospital Medicine’s (SHM) annual meeting in National Harbor, Md., just outside Washington, D.C.

Day Four highlights from HM15, the Society of Hospital Medicine’s (SHM) annual meeting in National Harbor, Md., just outside Washington, D.C.

Day Four highlights from HM15, the Society of Hospital Medicine’s (SHM) annual meeting in National Harbor, Md., just outside Washington, D.C.