Selecting and Implementing a Meaningful EHR System

1. Selecting and Implementing a Meaningful EHR System

2. Speakers David Groves, HealthBridge Executive Director, Tri-State Regional Extension Center Mary Zile, Director, Practice Consulting, Tri-State Regional Extension Center REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

3. Overview Many Good Systems • Tri-State REC has 5 supported EHR systems • Preferred pricing & contract terms Looking For the Best Fit for Your Practice • ‘First Look’ at an EHR Office Flow • Evaluate Your Initial “Need versus Want List’ • Vendor Demonstrations • Qualifying Vendors • Differentiating Factors • Vendor Bids • Vendor Quotes • Site Visits to Look at Qualifying EHRs • References • Informed Decision • Contract Analysis REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

4. Qualifying Vendors • Narrow the Field Down to 3 – 4 Serious Contenders • Looking at only one system does not provide adequate context in which to make an Informed Decision • Narrow the Field Down • ONC-CCHIT ATCB Certification • Functionality for Physicians, Providers, and Staff • Price Range / Budget • REC Supported Vendors • Infrastructure Model • ASP vs. Client/Server • Best in KLAS Rankings • Existing Business Relationship • Colleagues’ Recommendations • EHR goals for Practice Transformation REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

5. Differentiating Factors • These factors are ALL important as they impact: • Learning Curve • Productivity • Clinical Quality • Staff Efficiency • Patient Engagement • Revenue • What is Important to Your Practice? • Ranking according to importance to your practice will help differentiate between systems and identify the Best Fitfor your practice REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

6. Soliciting Vendor Bids Request For Bid (RFB) • Gather information and understand each vendor’s functionality • Rate the contenders against your Differentiating Factors • Use an objective scoring methodology REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

7. Vendor Quotes Standardized Format • Enables head-to-head price comparison • Roll everything up into 5-yeargrand totals for: • Software • Services (e.g. implementation) • Hardware REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

8. Compare “Apples to Apples” • Use 5-Year Totals for Comparison • Eliminate Vendors that Don’t Fit Your Budget • Lowest Cost/Point • may be your Best Value REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

9. Vendor Demonstrations • Provider Productivity Doesn’t (permanently) slow doctors down • Enhanced Ability to Streamline Staff Efficiencies • Staff’s ability to do a better job in less time, or improved work flow • Intuitive Functionality Easy to learn • Easy Navigation Not too many clicks / screens • Enhances Quality Eliminates errors / Cuts waste • Enhances Revenue Better coding / Fewer denials REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

10. Site Visits • “A Day in the Life of a Digital Practice” • See a practice during peak work hours • Observe key work-flows • Have time to talk to the staff and providers • How well would this EMR fit in your practice? • Think About the Impact of this EMR in Your Practice: • How would it effect Productivity? • How would it effect your staff’s Efficiency? • How wouldQuality be effected? • Would there be an impact on Revenue? REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

11. References • Balance the vendor’s hand-picked references with some un-biased references as well • Look for Value: • Effectiveness • Efficiency • Fulfillment of promises • Ability to adapt to changing requirements Will the vendor be a good partner? REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

12. Informed Decision • Define Roles • Sponsors, Deciders, Project Managers, etc. • Who gets to vote? • Follow the Process • Gather Information • Objectively rate/score the responses • Analyze the data • Look For: • Best Functionality • Best Value • Where are you willing to compromise? • Formalize & Communicate Your Decision REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

13. Contract Analysis • There may be several contracts for your lawyer to review: • Purchase Agreement • Support & Maintenance Agreement • Services Agreement (implementation, etc.) • HIPAA Agreement • Research Agreement • Some things to look out for: • Asymmetrical indemnity – get equal protection for both parties. • Unilateral acceptance – need mutual agreement on project plan, training schedule, customization, start dates, etc. • Vague credentials – demand a qualified training/implementation team. • Data mining – require authorization before your data (even blinded) can be shared. REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

14. Implementation Overview The implementation phase is where the rubber meets the road. Question: Why does one practice have great success with their EMR while another practice has a horrible experience with the same EMR? Answer: The difference is all about the implementation plan. Avoid the hazards and find a safe route around the barriers. REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

15. Collaborative Implementation Plan • Start with the vendor’s implementation plan, and adjust for the specifics of your practice. • Keeping the REC involved will help ensure: • Alignment with the practice’s goals. • Alignment with PCMH. • Alignment with Meaningful Use. • Lessons learned: • Vendors have a technical focus. • Human factors need to be addressed as well, e.g. how to ease the pain of change. • Training on new/altered work-flows is as important as learning the software. REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

16. Technical Assessment • What infrastructure is needed to support our Health Information Technology? • Can we re-deploy any of our current equipment? • Do we need a wireless network? • Is our internet connection fast enough? • What do we need to do about data security? • Lessons Learned: • An out-sourced, local IT support company is often a good idea for a small practice – they can perform the tech assessment, maintain the peripheral hardware, and solve problems REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

17. Hardware Lessons Learned • Aim for performance beyond “minimum specifications,” resulting in disappointing performance (speed) • Hardware expenditures can easily constitute 40% - 50% of your total EHR investment – consider insurance and warranties • Medical-grade servers – if your practice lacks the capacity to have a data center with dedicated power and HVAC, then an ASP or co-location infrastructure model is preferable • Consider extended-life batteries for lap tops; buy extras and dedicate space for charging REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

18. Software • Lessons Learned: • Understand your vendor’s pricing structure and purchase enough licenses – you don’t want to be caught short • Evaluate software update requirements • A testing / training / simulation environment is well worth the extra licensing cost REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

19. Health Information Exchange HIE connectivity is a major component of Meaningful Use alignment and offers an “early victory” in efficiency gains for the practice • Lessons Learned: • Get hooked up early – four to six weeks implementation lead time • Ensure interface functionality – structured data flowing into your EMR • Turn off fax and paper information flows REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

20. Quality Reports This is another important part of Meaningful Use that may get temporarily overlooked in all the activity of an EMR implementation • Lessons Learned: • Focus on quality report output from the beginning, when: • Choosing your MU “menu set” measures • Mapping interfaces and configuring database fields • Delineating required fields • Customizing your documentation templates • Re-engineering office and clinical work-flows • Designing the training curriculum REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

21. Data Conversion • The pros of data conversion may be outweighed by the cons… • Lessons Learned: • Data conversion can be expensive • Although conversion can speed transition to an EMR, it can also bea source of inaccurate data • If conversion is omitted, a patient’s presence in the EMR can be the authoritative check for converted charts REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

22. Work-Flow Re-Design & Template Customization • Address weaknesses • Involve staff in practice re-design • Analyze / design / implement – • then re-analyze / re-design / re-implement • Adjust process with goal of • PCMH and MU REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

23. Patient / Practice Communication Chart Abstraction & Pre-Loading Timing is important Be careful what you pre-load Pre-loading is a form of training Let your patients know what is going on Ask for their patience Training Let your patients know what is going on Ask for their patience Testing / Simulation Important phase – don’t miss it Go - Live Massive resources at go-live Big Bang or ease into it? Cut the schedule? Re-Assessment & Follow-Up Circle back Productivity ramped up to baseline? Anybody struggling? REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services.

24. EHR Goals for Practice Transformation • Patient Centered Medical Home • Meaningful Use is the use of a Certified EHR: • In a meaningful manner such as e-prescribing or providing a patient with an electronic copy of their clinical record. • For electronic exchange of health information to improve the quality of health care. • To submit Clinical Quality Measures (CQM) and other measures as selected by the Secretary of HHS. REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

25. Joint Principles of PCMH • Personal Physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. • Team Care - the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients • Whole Person Orientation - the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. • Care is Coordinated - across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). • Care is facilitated by Information Technology – EHRs, Registries and Health Information Exchanges are utilized to support optimal patient care, performance measurement, patient education, and enhanced communication • Enhanced accessto care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff. • Quality and safetyare hallmarks of the medical home and Physicians in the practice accept accountability for continuous quality improvement REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

26. PCMH Recognition Standards • Enhance Access and Continuity:Accommodate patient needs with access and advice during and after office hours; provide patients with team-based care • Identify and Manage Populations:Collect and use data for population management • Plan and Manage Care:Use Evidence-based guidelines for preventive, acute and chronic care management. • Provide Self Care Support and Community Resources – Assist patients and their families in self-care management with information, tools, and connections to community partners • Track and Coordinate Care: Track and manage referrals, care transitions, and clinical results. • Measure and Improve Performance:Use data to continuously measure and improve care quality and patient experience. REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

27. http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

28. Value-Driving Elements of Patient Center Medical Home and Accountable Care Organizations • Enhanced Access • Better Care Coordination • Better Health IT • Payment Reform for Primary Care REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

29. Dear Colleagues: As you may know, the topic of patient-centered care is dear to my heart. I believe that, of the six IOM Aims for Improvement - safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity - “patient-centeredness” is the keystone and that, from it, the others properly devolve. To me, “patient-centered care” is care that respects each person as an individual, honoring his or her backgrounds, their families and their choices. Donald M. Berwick, MDAdministratorCenters for Medicare and Medicaid Services Source: Better to Best Report - Value-Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations, March 2011

30. Raising the Bar for PCMH NCQA Releases New Standards for PCMH PCHM 2011 • More Patient-Centeredness required • Increase emphasis on Patient Feedback • Federal Meaningful Use Language is embedded in the standard • Greater emphasis on the use of HIT • Reinforces incentive to use HIT to improve quality • Implements 6 “must pass” elements

32. PCMH 2011 and Meaningful Use Meaningful Use Requirement Found in PCMH Standard • Electronic Prescribing • Drug Formulary, drug-drug, drug-allergy checks • Maintain active problem list and current diagnosis and meds • Record patient demographics including race, ethnicity and preferred language • Record and chart changes in vital signs • Record smoking status • Report quality measures • Implement clinical decision support • 3E: Use Electronic Prescribing • 3E: Use Electronic Prescribing • 2B: Clinical Data • 2A: Patient Information • 2B: Clinical Data • 2B: Clinical Data • 6F: Report Data Electronically • 3A: Implement Evidence-based Guidelines

33. Summing Up • Health IT is essential to PCMH recognition • Health IT elements that enable practice transformation • Certified EHR system • Disease Registry (within or integrated with the EHR) • Patient Portal supporting • Electronic receipt of patient care information and results • Schedule requests • Prescription refill requests • Secure patient-provider e-mail • Information about the primary care practice and services • Patient surveys • Health Information Exchange supporting • Results delivery • Electronic Referrals and Transitions of Care • Future EHR Certification and Meaningful Use Requirements will be influenced by evolving aspirations for PCMH

34. Questions? This presentation will be posted at: TriStateREC.org REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

35. END REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

36. Objective Scoring Tool Weighted Decision Matrix • Award points to vendor responses • Total points in each category (differentiating factor) • Multiply points by the weight you assigned • Grand total score will rate how well the vendor’s functionality meets your needs REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

37. Vendor Responses REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

38. Open-Ended Questions REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

39. Compare Scores • Add up scores in each category • Highest overall score means this vendor is most likely to perform well in your practice • Highest score is also an indication of Best Functionality • Eliminate vendors that “settle to the bottom” REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

40. Vendor Quotes REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

41. Services Quotes REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

42. Hardware Quotes REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

43. Vendor Demonstrations REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

44. Site Visits REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .

45. References REC support is provided under cooperative agreement 90RC0025/01 from the Office of the National Coordinator for HIT, US Dept. of Health and Human Services .