), I’m particularly excited about the June 2019 issue because the content is an excellent representation of how we see 

’s niche going forward. Specifically, the goal is to straddle the space where implementation science, health services research, and applied management and systems science meet. This is a lot of space to cover, but it is incredibly important if healthcare in the United States is to achieve greater value for resources expended.

While partnerships between scientists and practitioners have led to improve&shy;ments in care delivery, the business of evidence creation has been dominated by academics and health scientists, often with little input from consumer advocates, industry representatives, and care providers. Likewise, innovations occurring in industry are often considered proprietary in a health system with significant profit motives. The result is that lessons on implementing scientific evidence are not disseminated enough, nor are innovative ideas studied with the level of rigor needed to influence policy, payment, and clinical training.

to provide a space for scientists and those involved in all facets of care delivery to interact and to communicate with those who set policy, regulations, and payment. 

will adhere to the principles of trans&shy;parency and scientific rigor, but it will also embrace the uncertainty that comes with applying science in real-world settings, publishing results from explor&shy;atory or pilot studies and informed commentaries from leaders in the field.

Low-value care is discussed from the perspectives of a patient advocate, a health plan, and a state policy maker. They highlight the success possible when such care is targeted and eliminated, as well as the delicate balance of communicating to patients the costs and benefits of treatment options.

Yunfeng Shi, PhD, and coauthors reflect on the success and limitations of the push to implement and use the capabilities of electronic health records and health information technology. Despite progress, there is more work to be done to achieve better care. The article highlights some of the political, economic, and market barriers that impede achieving that potential.

Two articles report on important topics from the field, including an article by Megan N. Whittet, MPH, and coauthors that focuses on health systems changes to address tobacco dependence; and an article by Bernadette Mazurek Melnyk, PhD, APRN-CNP, that focuses on clinician burnout.

I hope you find the content in the June issue of 

useful in your work, and I encourage you to think about contributing your own content for future issues. We are quite willing to work with potential authors, many of whom may not have experience with publication, to help frame and develop their work to meet the publication and scientific standards of 

Articles

Editor’s Letter: Dennis P. Scanlon, PhD

The American Journal of Accountable Care. 2019;7(2):12-14

More than half of all clinicians throughout the United States experience symptoms of burnout.

 The constellation of burnout, depression, and suicide in clinicians is now a public health epidemic that is having adverse effects on the quality and safety of healthcare. Burnout manifests itself by emotional exhaustion, no longer finding work as meaningful, and feelings of ineffectiveness, as well as a tendency to view patients, students, and colleagues as objects rather than as human beings.

Burnout has many adverse consequences, including lower job satisfaction, higher turnover rates, increased rates of alcohol and drug abuse, and suicide, in addition to higher rates of medical errors and decreased patient satisfaction.

 Although clinicians work to provide the highest quality of care for their patients, they often do not prioritize their own self-care. As a result, physicians, nurses, and other healthcare providers are often plagued by chronic conditions and mental health problems. Findings from a recent national study of nearly 1800 practicing nurses from 19 healthcare systems throughout the United States indicated that more than 50% reported being in suboptimal mental or physical health.

 Compared with nurses in better health, those in poorer health were 26% to 71% more likely to have made medical errors. Depression affected approximately one-third of the nurses and was the leading cause of medical errors. Further, those who worked 12-hour shifts had poorer health and made more errors than those who worked fewer hours. Nurses who perceived their work site as supportive of their health and well-being reported better health. Although registered nurses comprise the largest healthcare workforce, they have higher levels of depression, fewer healthy lifestyle behaviors, and poorer physical health than physicians and the general population.

Not only is burnout detrimental to clinician population health and the quality and safety of healthcare, but it also contributes to huge financial losses. It is estimated that $500,000 to $1 million in revenue is lost when a physician leaves a practice.

 The loss of a newly licensed registered nurse (NLRN) in the first year of practice costs the organization up to 3 times the nurse’s annual salary when taking into consideration the cost of recruitment, training, and orientation.

 Nearly 60% of NLRNs leave their first professional position within the first 24 months, often due to high stress and burnout.

There are multiple causes of burnout in clinicians, including both personal and system factors. Personal factors include not engaging in good self-care and healthy lifestyle behaviors, such as making time for regular physical activity, engaging in healthy eating, getting adequate sleep, and practicing daily stress reduction. Malalignment of a clinician’s role with their purpose and passion also leads to issues with presenteeism and burnout. However, multiple factors within the healthcare system also contribute to clinician burnout and depression. These include poor staffing patterns that result in imbalanced clinician—patient ratios, long shifts, ongoing challenges with electronic health records that result in less time with patients, and pressure to increase caseloads.

 Loss of autonomy and a sense of powerlessness are other sources of burnout, along with inadequate leadership support and work cultures that do not support clinician well-being. A lack of trust in, connection to, or support from coworkers also leads to social isolation and dissatisfaction and contributes to the problem of burnout.

First and foremost, it is important to implement a multicomponent comprehensive strategy that entails building a culture of well-being in which healthy choices are the norm within a system.

 There is a longtime saying that “culture eats strategy for breakfast, lunch, and dinner.” Healthcare systems must build a culture of wellness in which leaders “walk the talk” and provide resources along with an infrastructure that supports it.

 If leaders and supervisors do not role model and support wellness, it is unlikely that their clinicians will engage in healthy behaviors. Wellness for clinicians needs to be built into the mission and values of the organization and made visible, as well as highlighted as important, throughout the onboarding of new clinicians to a system. Evidence-based interventions must be targeted to individual clinicians, the community of practice, the workplace culture and environment, and institutional policies. All clinicians should be made aware that their well-being is an important priority for the organization, and they should be made knowledgeable of wellness resources within the institution that are available to them. It is critical to have a “menu of options,” as not all interventions will resonate with everyone. Grassroots tactics, such as wellness champions (individuals who volunteer a few hours every month to help build a culture of well-being in a system), are a low-cost but very effective strategy in helping to create a culture of well-being throughout an organization.

Breaking down the stigma of mental health disorders for clinicians is important so that those at risk can receive evidence-based treatment. For healthcare systems that do not offer annual personalized health or wellness assessments for all employees, clinicians should be offered the opportunity to be screened for depression, anxiety, and burnout without concern regarding risk to their employment should they screen positive for mental health problems. Those at risk with symptoms should be offered evidence-based interventions, such as cognitive-behavioral therapy or cognitive-behavioral skills building, which have been shown to be effective in reducing these symptoms with clinicians.

 The Healer Education Assessment and Referral Program is a useful system that provides anonymous encrypted risk screening in partnership with the American Foundation for Suicide Prevention. Although mindfulness interventions with clinicians tend to be time intensive, findings from studies indicate that they have resulted in improvements in stress and anxiety.

Healthcare system issues that are known to cause burnout must be addressed. Staffing patterns must be improved where patient—provider ratios are high, and 12-hour shifts should be eliminated. Changes to the electronic health record system also are necessary so that clinicians can spend more time with their patients. Scribes should also be considered, as they could decrease the data entry workload of healthcare providers.

Return on Investment and Value of Investment

For every $1 that is invested in wellness, findings from studies have indicated a $3 to $4 return on investment (ROI) for organizations that invest in building robust wellness programs for their employees.

 As an example, The Ohio State University, a large land grant university with a large academic health center comprising 7 hospitals, accelerated its wellness initiative and was the first institution of higher learning to appoint a chief wellness officer (CWO) in 2011 to spearhead a comprehensive integrated strategy designed to enhance the well-being of faculty, clinicians, staff, and students. At Ohio State, interventions are targeted to individuals, the social and family network, the culture and environment, and policy. For every dollar invested in wellness, the university has a $3.65 ROI and is in a negative trend for healthcare spend for the third year in a row, whereas other institutions have been experiencing upward trends of 4% to 6% annually in healthcare spend. Value of investment is now being assessed beyond ROI and includes factors such as better morale, higher job satisfaction, less presenteeism and less absenteeism, and higher patient satisfaction.

An Urgent Call for Action by the National Academy of Medicine

Because of the disconcerting rate of clinician burnout, depression, and suicide, the National Academy of Medicine (NAM) launched an Action Collaborative on Clinician Well-being and Resilience in 2017 to enhance visibility on this issue and to develop evidence-based solutions to tackle this public health epidemic.

 As a key strategy to address this problem, the NAM collaborative has emphasized the urgent need for healthcare systems to prioritize the hiring of CWOs whose responsibility is to spearhead a culture of well-being and implement strategies to create a healthier workforce.

 CWOs should have a role within the C-suite to elevate the importance of the position and be equipped with the needed resources to effectively build cultures of well-being and implement evidence-based interventions, as described here, to enhance well-being in clinicians.

It takes numerous years, even decades, to translate evidence generated from research into real-world practice settings.

 The time gap between what is known and what is done is lethal.

 We must not wait decades to place high priority on preventing and reducing clinician burnout, depression, and suicide. Urgent attention and action on this public health epidemic will not only improve clinician well-being and save lives, but it will also improve the quality and safety of the US healthcare system, which the public and health of our nation rightly deserve.

 The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Concept and design; acquisition of data; and drafting of the manuscript.

Bernadette Mazurek Melnyk, PhD, APRN-CNP, Vice President for Health Promotion, Chief Wellness Officer, and Dean, College of Nursing, The Ohio State University, 145 Newton Hall, 1585 Neil Ave, Columbus, OH 43210. Email: melnyk.15@osu.edu.

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7. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. 

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. 2002;136(5):358-367. doi: 10.7326/0003-4819-136-5-200203050-00008.

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. 2005;13(3):149-155. doi: 10.1111/j.1440-1854.2005.00677.x.

11. Wetterneck TB, Linzer M, McMurray JE, et al; Society of General Internal Medicine Career Satisfaction Study Group. Worklife and satisfaction of general internists. 

. 2002;162(6):649-656. doi: 10.1001/archinte.162.6.649.

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13. Bass K, McGeeney K. U.S. physicians set good health example. Gallup website. gallup.com/poll/157859/physicians-set-good-health-example.aspx. Published October 3, 2012. Accessed April 30, 2019.

14. Unruh LY, Zhang NJ. Newly licensed registered nurse job turnover and turnover intent. 

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Intervention Effects of a Cognitive Behavioral Skills Building Program on Newly Licensed Registered Nurses

 [PhD thesis]. Columbus, OH: The Ohio State University College of Nursing; 2019.

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Clinician burnout is currently a public health epidemic that is threatening the quality and safety of healthcare. Solutions for action by healthcare systems are offered.

Making an Evidence-Based Case for Urgent Action to Address Clinician Burnout

The American Journal of Accountable Care. 2019;7(2):18-19

Reducing low-value care can free up money to be spent on high-value services, but it’s a delicate conversation to have, according to panelists at the University of Michigan Center for Value-Based Insurance Design (V-BID)’s V-BID Summit, held March 13 in Ann Arbor, Michigan.

The concept of value is well known among health policy experts, the payer community, and policy makers, but patients do not necessarily have the same idea of what value means, explained Daniel Carey, MD, secretary of Health and Human Resources for the Commonwealth of Virginia.

For instance, when the concept of value is introduced into a conversation around achieving access to care, some stakeholders might get the wrong idea, he said.

“For some, I found out in the last 6 or 8 months, that sounds like we’re trying to reduce access…trying to take something away,” Carey explained.

The language being used in these discussions is crucial, said Gwen Darien, BA, executive vice president for patient advocacy and engagement at the National Patient Advocate Foundation. Her organization represents approximately 150,000 patients who are primarily low income and underresourced and have trouble accessing quality, affordable, and equitable care.

Patients don’t think about the mathematical formulas that policy makers and other experts in the field are using to define value and remove services that are considered low value because they might cause harm or be unnecessary. Instead, patients are concerned with a notion ingrained in American culture that if something is being taken away from them, then they’re being stinted.

The conversation has to make it clear that services are being taken away in order to keep patients safe from harm, she added.

“A lot of the ways that we’ve talked about reducing low-value services [have] had to do with waste and waste in the system,” Darien said. “People do not want to hear that anything that their doctor is prescribing for them is wasteful.”

That’s why explaining the harm of unnecessary or low-value services is important and can help the patient understand that the concern is keeping them safe.

“Less can often be more, because more can lead to unintended consequences,” she added.

When Cigna talks about reducing low-value services, many times people interpret that as taking away care, according to John Keats, MD, national medical director for affordability and specialty partnerships at Cigna. But the company tries to be very deliberate in using evidence generated by other organizations and the recommendations of the United States Preventive Services Task Force (USPSTF) to make decisions on low-value care that can be removed. A D rating from the USPSTF means that a service is not recommended to be used in asymptomatic patients.

One service that the panelists gave as an example of a low-value service that is used often and can be mostly cut out of the system is vitamin D screening. Cigna defined a population for whom vitamin D screening was recommended and would not pay for the test for any patients who didn’t meet those criteria. According to Keats, a year later, doctors have stopped ordering the test and it has saved $20 million.

“This whole idea of low-value care, I think, is great, but what I see time and again [is]…we have to be on the lookout for low-value physicians,” Keats said. “At the end of the day, this is physician-driven.”

Beth Bortz, president and chief executive officer of the Virginia Center for Health Innovation (VCHI), was in the audience and mentioned that some physicians don’t even realize they’re ordering the test as often as they are. She related the story of a member of USPSTF with whom VCHI was working in its quest to identify and measure uses of low-value care, who saw his data on vitamin D screening and thought that the data must have been wrong because he would never order that many vitamin D screenings. But when he dug into the data, he realized that a vitamin D screening was part of a bundled laboratory order, and he was ordering it far more often than he realized.

“I think that’s a big piece of the secret sauce [to reducing use of low-value services],” Bortz said. “They have to sit with [the data], look at it, dig into it.”

Carey admitted that there is pushback even from physicians when it comes to removing low-value care, and it’s not because they think low-value care utilization isn’t an issue. Most physicians agree with the concept of removing low-value care, but they worry that it will be overinterpreted and that the 5% or 10% who do need the service will miss out on it. The pushback, he clarified, has been on an “inflexible system” that doesn’t allow leeway for someone to step off and provide services that might be of low value for the majority of people but fit for that specific patient.

All this work to remove low-value care can have real benefits for patients, as it saves money that might have been used on unnecessary services and frees those dollars up for high-quality services to be used. Darien used the example of lung cancer, where if money is freed up, all patients can get their tumors sequenced so they are given the right treatment that will have the best chance of working for them instead of being treated “scattershot.”

“That’s removing low-value care to add high-value care,” she said.

In Virginia, VCHI just received $2.2 million to launch a 3-year statewide pilot to reduce the use of low-value care. The pilot will bring together 6 health systems and 3 clinically integrated networks to form a large-scale health system learning community and will also create an employer task force that includes employers, the Virginia Chamber of Commerce, and the Virginia Business Coalition. This is the next step after the work that Virginia has done to identify and measure low-value care utilization.

“Once we’ve moved the dial, then we’ll explore the headroom,” Carey said. “We need to turn waste into real dollars.”

The concept of value is well known among health policy experts, the payer community, and policy makers, but patients do not necessarily have the same idea of what value means.

Reducing Low-Value Care May Mean Tough Conversations With Stakeholders

The American Journal of Accountable Care. 2019;7(2):22-23

Let’s say you’re a physician and you are trying to explain to your patient why a particular procedure or treatment option does not represent a good value. You can talk about value in a variety of ways. You don’t want to waste the time that it will take the patient, and the providers, to deliver that treatment. You can explain that all medical treatment costs money, and this option is expensive compared with other approaches. Or you can point out that all medical interventions carry some level of risk, and the benefits of this one are quite low relative to those potential risks. Whatever the reason, the treatment is considered low value.

Treatment choices should always provide the highest possible value to every patient within the parameters of evidence-based medicine. No one wants to waste resources or engage in practices that don’t work very well, significantly impair quality of life, or incur costs equal to or higher than those of other effective treatments.

But for many patients, what makes sense to the physician and reflects evidence-based practice can seem abstract, impersonal, or even threatening. The problems can arise because although providers and patients often share the same goals for their care and treatment, they use different language or understand language differently when it comes to having discussions about what constitutes high- versus low-value treatment. The success or failure of conversations about value in healthcare frequently hinges on the words that are used in these discussions and the way that the options are explained to individual patients.

This cognitive and semantic dissonance begins with the word “value,” a word that can mean many things depending on who says it and in what context. For healthcare providers, value generally connotes an algorithm that measures benefits versus costs. In most cases, value includes an assessment of the resources required to produce the desired outcomes. Resources almost always involve money, the cost to the system or the patient, but can also encompass time or opportunity costs. At one end of the spectrum, treating advanced cancer that has failed to respond to other therapies with a fourth or fifth line of chemotherapy, which is expensive and causes significant adverse events, is very likely to be low value. At the other, an emergency department visit, x-ray, and specialist consultation for a simple ankle sprain may be less dramatic, but also clearly low value. Both interventions allocate resources for interventions that have very low probabilities of achieving good outcomes for the patient. Nonetheless, patients may push for these and other low-value approaches because they perceive a potential individual benefit.

When patients talk about value, however, resource allocations, direct costs, time, and the other factors that go into developing the algorithms are far from their minds. Patients generally aren’t interested in or knowledgeable of mathematical formulas when they think about their healthcare decisions. They want to know if you can cure their cancer or, if you can’t, how long and how well they can live. They want to be reassured that their swollen ankle isn’t really broken. Value for patients means getting what matters most to that patient at that specific time in their lives. Value is most often an individual, personal assessment rather than an evidence-based, systemic one.

This can mean that when the doctor talks about a treatment being low value, the patient may hear that they are not worth the time, effort, or costs involved in delivering that treatment. That physician may be trying to save the patient from something that is unnecessary or ineffective, whereas patients perceive that something is being taken away from them. Doctors may frame their recommendations in terms of what is wasteful to the system. Patients think less about the system and far more about their individual needs and wants, and they tend not to want to hear that their treatment is “wasteful” or “low value.”

Issues related to language and perception are often more prevalent and more serious with traditionally underserved populations. Medicaid patients and those who face severe financial toxicity can be highly sensitive to the idea that they, not the treatment options, are low value. They may fear that they are being offered lower-level care because they lack the resources to pay for the higher-end treatments available to others. For these vulnerable patients, words like “wasteful” or “high cost” can sound like code that means “I’m getting a lower tier of treatment.”

Physicians and other healthcare providers who engage in treatment decision making with patients can avoid both these misunderstandings and their consequences by becoming more aware of the language they use when they talk to every patient about high- and low-value care. It is critical and in everyone’s best interest to identify and reduce the low-value care that we deliver in our healthcare system. We do not have unlimited resources, and we do have to make rational, systemic decisions about how best to use what we have. In addition, we are currently in the midst of a remarkable era in which new, highly effective, individualized treatments are emerging. Removing the waste and low-benefit interventions from our medical care system is one path to freeing the resources needed to ensure that everyone has access to these advances. We can, for example, see real, documented high value in genomic sequencing for patients with lung cancer who can then benefit from targeted therapies rather than more scattershot, less effective treatments.

Patients need to understand the meaning of low- versus high-value treatments in terms that they understand and that address their values. Physicians can help this happen by talking specifically about benefits and risks for the individual patient, not the system. What we will learn from this procedure that will make a difference in how we treat your condition? What does this drug cost compared with one we think can be just as effective? Can we have a treatment plan that doesn’t require you to come to the clinic as often? What can you realistically expect in terms of a longer life, or quality of life, if we do another round of chemotherapy instead of palliative care?

In the end, it is all about effective communications between providers and their patients, and effective communications depend on trust. Trust is never a one-way street. Patients, of course, need to trust their providers, but providers need to trust their patients to know what matters to them. Conversations that take place about what is high or low value have to keep the individual patient’s care, safety, and best outcomes at their heart, and they must be true dialogues, shared and understood by everyone involved. That is, in itself, a very high value.

National Patient Advocate Foundation and Patient Advocate Foundation, Washington, DC.

Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.

Gwen Darien, BA, National Patient Advocate Foundation and Patient Advocate Foundation, 1100 H Street NW, Ste 710, Washington, DC 20005. Email: gwen.darien@npaf.org.

Ensuring that patients get high-value care is critical, but value can have different meanings to patients and providers. It is important to know what matters to patients and to use language that reflects those values.

Language Matters: Talking About Low-Value Healthcare With Patients

The American Journal of Accountable Care. 2019;7(2):24-25

We all have an obligation to serve as good stewards of America’s healthcare dollars, and healthcare companies can go further and seize the opportunity to drive systemwide improvements to deliver more value for those we serve. Three years ago, Cigna created a national role dedicated to identifying opportunities to extend healthcare dollars while maintaining or improving the quality of care. (The term “Cigna” as used herein refers to operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company.) This is my role, and I am 100% focused on increasing the value of medical care that customers receive.

Unfortunately, in the United States, medical culture often assumes that more expensive care equates to better care. In fact, studies have shown that higher-quality care may cost less, and our goal as providers and payers of healthcare should be to move the healthcare system to one that is focused on value over volume.

To do so, we must identify and curtail the use of so-called low-value medical care.

 These are tests, imaging studies, procedures, and medications that lack evidence of improved health outcomes and may even be harmful by leading to needless anxiety or further testing and procedures that carry the risk of complications. Although challenges exist in identifying sources of low-value care, there are several road maps we can follow.

One approach is to monitor the recommendations of the US Preventive Services Task Force (USPSTF), which is part of the federal government’s Agency for Healthcare Research and Quality. USPSTF offers a category D recommendation that is defined as “not recommended” and states, “The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”

 As healthcare companies, we can discourage use of these potentially ineffective or harmful practices by incorporating the USPSTF recommendation into appropriate coverage policies. Resulting coverage determinations are balanced by appeal rights that allow for coverage when the potential benefit outweighs the risk for individuals and is deemed medically necessary.

Another source of low-value care identification is 

 More than 80 medical specialty societies and other organizations have contributed lists of medical services to avoid or to at least be subject to a discussion of relative risks and benefits between healthcare providers and patients. These lists can also be utilized as support for coverage and reimbursement policy decisions.

Specialty societies may also address issues of low-value care through clinical guidelines, as was the case in 2015 when the Endocrine Society released guidance regarding routine screening for vitamin D deficiency. The screening had become a widespread practice when the organization came out with guidance that stated, “Screening is recommended for individuals at risk for vitamin D deficiency. Population screening or screening of those not at risk is contraindicated.”

 Based on this position by the professional society of the country’s leading experts in the field, Cigna began a process to examine utilization and found that many customers were receiving this unnecessary and potentially misleading test. Through Cigna’s purposefully cautious and deliberate process, it was determined that we should no longer reimburse vitamin D testing when done as a routine screening in populations not at risk for deficiency. The new policy went into effect in early 2018, and we were the first major healthcare company to adopt this position. Since that time, Cigna has reduced spending on unnecessary vitamin D testing by more than $20 million (Cigna Business Analytics, unpublished data, April 2019).

Ultimately, eliminating low-value care in the US healthcare system will depend in large part on changing healthcare provider behavior. Providers need to be encouraged to monitor and adhere to the recommendations of expert voices like the USPSTF, 

, and their own professional organizations. Healthcare companies need to educate providers and customers alike to question care that is unnecessary or of unproven value. Working together, we can help eliminate wasteful spending and deliver on our goal to improve the health of Americans by delivering higher-quality care at lower cost.

 Dr Keats is employed as a senior medical director for Cigna and receives a small number of stock shares and options based on employment.

Concept and design; analysis and interpretation of data; drafting of the manuscript; and supervision.

John P. Keats, MD, Cigna, 900 Cottage Grove Rd, Bloomfield, CT 06002. Email: John.Keats@Cigna.com.

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Working together to reduce low-value care, stakeholders can help eliminate wasteful spending and deliver on their goal to improve the health of Americans by delivering higher-quality care at lower cost.

Curtailing Utilization of Low-Value Medical Care

This commentary provides several reflections on the recent annual report to Congress by the Office of the National Coordinator for Health Information Technology, which highlighted the key elements in its electronic health record (EHR) incentive programs, renamed Promoting Interoperability in 2018. We discuss 3 important aspects of health information technology (IT) in connection with interoperability and accountable care: health IT as a key element to care integration and delivery by health systems, the potential harm of EHR vendor consolidation, and overcoming barriers and realizing value in providers’ experience with health IT.

The American Journal of Accountable Care. 2019;7(2):15-17

Since the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009,

 more than $30 billion has been paid to healthcare providers as incentives for adopting and using electronic health records (EHRs).

 In 2018, CMS renamed its EHR incentive programs (formerly known as Meaningful Use) to Promoting Interoperability (PI) and signaled the federal government’s prioritization of interoperability and health information exchange in its continued efforts to advance health information technology (IT) in care delivery.

 In its recent annual report to Congress, the Office of the National Coordinator for Health Information Technology (ONC) highlighted the key elements in PI and its vision of the future state of health IT.

 This commentary provides several reflections on the ONC report as well as on PI, based on the authors’ work in the area of health IT. We discuss 3 important aspects of health IT in connection with interoperability: health IT implementation in health systems, the potential harm of EHR vendor consolidation, and overcoming barriers to effectively using health IT in provider experience.

Health IT Is a Key Component of Integrated Care Delivery by Health Systems 

An important change in the landscape of healthcare over the past 2 decades is the proliferation of health systems, resulting from horizontal and vertical integration of healthcare providers.

 Functioning as parent organizations to hospitals, physician groups, and potentially other ambulatory care facilities (eg, skilled nursing facilities), health systems have the promise of delivering efficient and coordinated care.

 A key component of integrated care delivery is the implementation and management of health IT at the health system level. When a health system takes a centralized approach to IT, all care delivery units within the system are likely to converge to a same EHR platform or even to a single-instance installation, potentially achieving better intrasystem interoperability. The stage 2 PI criteria “encourage the exchange of information in the most structured format possible”

 and thus may further incentivize centralized IT decision making among health systems. Moreover, health systems’ postimplementation IT management strategies (eg, how the use of decision support tools is monitored) and governance (eg, the existence and the composition of an IT steering committee) directly impact the effectiveness of the actual use of health IT to improve outcomes.

However, to date, there is limited empirical understanding of health IT from a health system perspective. For example, how is health IT implemented differently across health systems? Are decisions related to health IT centralized in health systems? If so, is there still much variation in the actual use of specific health IT functionalities (eg, decision support tools) within large systems? Do health systems enhance patient access to their health records by prioritizing certain types of functionalities (eg, patient portals)? How well do ambulatory care units and hospitals within a health system “communicate” through the EHR? The answers to these questions would illuminate the role of health IT in health systems’ efforts to achieve accountable care.

Equally important, there are still many independent ambulatory care providers (ie, ambulatory clinics and other outpatient care facilities outside health systems), and we know little about their adoption and use of health IT, especially in terms of the scope of functionalities. Despite the continuing trend of consolidations, independent providers collectively may remain an important segment of care delivery in the near future. According to a recent survey, 75% of solo practitioners plan to remain independent.

 In the context of PI, we need insights from investigations comparing independent providers with those within health systems regarding their current use of health IT, data sharing capabilities, and strategies to address interoperability.

EHR Vendor Consolidation Is Potentially Harmful to Interoperability and Data Sharing

A competitive health IT product market would be important to the pricing and quality of EHRs, and it has been argued that competition among EHR vendors can improve interoperability.

 Earlier studies have found that the EHR incentive programs under HITECH enhanced competition in the EHR market, as reflected in the increased number of vendors.

 However, more recent trends caution against being overoptimistic about the competitiveness of the EHR market. By 2018, 2 of the leading vendors, Cerner and Epic, together captured more than half of the acute care hospitals, and their market shares continue to grow.

 Although less documented, there is evidence of a similar trend in the ambulatory care EHR market. Based on the Minnesota e-Health Initiative report,

 the proportion of ambulatory clinics in Minnesota using Epic increased from 51% in 2016 to 59% in 2018.

 The ongoing focus on interoperability, along with provider consolidations, may have contributed to the increasing trend of concentration in the EHR market. Based on the American Hospital Association’s Annual Survey and IT Supplement (2012-2016), a recent analysis reported that 35% of the hospitals switched to the EHR vendor of the acquiring health system within 3 years of consolidation (the proportion is likely to be higher after 3 years), whereas another 21% had the same EHR vendor before the consolidation.

 Interoperability has become a key determinant in EHR vendor choices

 and is likely to be further prioritized as PI progresses to the next stage. Health information can often be exchanged more efficiently (or more easily) among EHR platforms from the same vendor. Hence, it is not surprising to see health systems and providers converging to a concentrated set of vendors. Moreover, to protect or to further increase market shares through competitive advantages, current leading EHR vendors may even strategically create barriers to information exchange with competing products, so that new adopters (or switchers) will be somewhat “forced” to choose the vendors that currently dominate the market.

 Reduced competition may also negatively affect the innovation, quality, and pricing of EHR products in general. In light of this, PI may need to be paired with regulatory (eg, data standards that encourage information exchange among different platforms) or incentive (eg, penalties for vendors that do not facilitate data sharing with competing platforms) policies to maintain a competitive EHR vendor market.

Overcoming Barriers to Better Health IT Experience for Providers

The ONC report outlined major barriers “associated with health IT capabilities and data sharing” (eg, financial and trust barriers) and those “associated with health care providers’ experience with health IT” (eg, barriers related to documentation and usability).

 In particular, “lack of alignment with real-world clinical workflows” was mentioned among the usability issues.

 These barriers, many of which can be conceptually linked to the technology acceptance model

 lead to frustration and lower the value of health IT as perceived by providers. The lack of interoperability is an important source of provider frustration in using EHRs,

 which in turn contributes to physician burnout.

 However, a recent study also found that the integration of ambulatory and hospital EHR systems, often an important step to improve interoperability, may decrease provider and patient satisfaction, partly due to the resulting changes in work processes.

These findings suggest the complex and multifaceted nature of provider experience with EHRs. At the root of the problem may be the competing demand for customization and standardization at the same time. Population-based longitudinal studies are needed to help us better understand the prevalence and trends of specific barriers among providers (eg, workflow changes or disruptive alerts), based on their actual experiences in using EHRs. Our empirical knowledge regarding barriers to effectively using health IT is particularly limited in ambulatory care. The success of PI relies on overcoming (or at least mitigating) some of these barriers. Coordinated efforts from health systems, frontline users, vendors, and policy makers are needed.

Health IT needs to be examined in the context of health systems’ increasing role in care integration and delivery. How to promote interoperability while maintaining the competitiveness of the EHR vendor market is an important policy question to be addressed. Overcoming major barriers and improving provider experience with health IT is a key element to the success of achieving value and accountable care.

 Department of Health Policy and Administration, The Pennsylvania State University (YS, DPS, AA-R), University Park, PA.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Concept and design (YS, DPS, AA-R); analysis and interpretation of data (YS); drafting of the manuscript (YS, DPS); critical revision of the manuscript for important intellectual content (YS, DPS, AA-R); administrative, technical, or logistic support (AA-R); and supervision (YS).

Yunfeng Shi, PhD, The Pennsylvania State University, 504 Ford Bldg, University Park, PA 16802. Email: yus16@psu.edu.

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The authors discuss health information technology in the context of health systems, the potential harm of electronic health record vendor consolidation, and overcoming barriers in providers’ experience.

June 2019

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