Implementation of an Electronic Health Record

1. Implementation of an Electronic Health Record Mark Ficker Vice President, Medical Group Services & Chief Financial Officer

2. Brown & Toland Overview

3. Community Physician Mission Leading organization of community and academic physicians Brown & Toland Medical Group is a leading organization of community and academic physicians. We are committed to providing superior, coordinated and comprehensive medical services. Owned and governed by physicians, we provide excellent healthcare, product choice, and value to our patients through clinical integration, innovation, and technology. Owned and governed by physicians

4. Brown & Toland Medical Group • IPA with 195,000 Members • 1,500 Physicians • Product Offerings & Services • Financial Health • Northern California Health Care Marketplace

5. Key Business Objectives Enhance Clinical Integration: Continue to develop processes and systems to clinically integrate care across the BTMG physician network. Health Improvement and Quality Improvement: Continue to promote clinically integrated, comprehensive patient health care through health improvement and quality improvement programs. Organizational Cost Reductions: Reduce organizational cost through improving the quality of patient care delivered and by continuing to implement administrative efficiencies. Network Diversification and Product Administration: Provide a comprehensive, cost effective, high quality network of health care and administrative services for all competitive medical benefit plan models. Physician Services: Provide administrative and point of care services that will efficiently manage the physician’s practice and enhance the overall quality of care provided. Regulatory Compliance: Continue to comply with all regulatory requirements. • Develop disease management programs • Develop an outcomes measurement program • Improving health in the community • Recognize, reward & assist high quality, efficient, & effective physician practices • Improve physician office staff education programs • Physician Office Services • Network Management • Product Development • Information Technology • Human Resources • RX Management • Claims administration & eligibility • Customer service • Care management • Quality improvement • Finance • Data Warehouse & DSS

6. Building a Strong Foundation

7. Lab • Radiology • Pharmacy • PT Ancillary Services • Eligibility Management • Care Management • Claims processing • Capitation management • General financials • Decision support • Internet • Member view of clinical record • Personal disease management • Self help • General Health Information Patient Education Administration Patient Intervention Patient Advocacy • Case management • Concurrent review • Wellness management • Preventive management • Disease management • Customer service • PCP assignment • Demand management • Credentialing Medical Knowledge Patient Access • Scheduling Online • Nurse advice • Physician access • eOffice Visits • Rx Renewals • Protocols • Pathways • Medical policies • Practice guidelines • Clinical decision support • Alerts & Reminders • Journals Population Management Medical Delivery • Primary care • Specialty consulting • Acute • Post acute Research & Education • Outcomes • Best practices • Research • Patient centric • Accessible services • Patient & MD is known to system • Care & care management is coordinated across the continuum • Clinical & administrative data is accessible enterprise-wide • Consolidated financial processes • Enterprise-wide reporting with “feedback loops” • Support for wellness and knowledge transfer to patient Core Medical Group Characteristics Brown & Toland Medical Group Characteristics

8. Staged IT Strategy: 2000 - 2008 Transformation Differentiate • HIPAA Remediation • Web EMR Options Analysis & System Selection • Clinical Protocols & Alerts • Physician/Patient Connectivity • Decision Support Reporting • Medical/Disease Management Programs • Evaluate CRM Options • Expanded Network Services • End User Device Standards • Remote Access Control • Operational Improvements • Physician Services – Integrated PMS & EMR • All Product Offering • Sustainability and Competitive Advantage Operational Efficiency & Regulatory Risk Assessment • IDX Optimization & Data Quality • RACER Replacement • Data Warehouse/Data Marts • InterQual Implementation • Web Foundations • Portal Development & eArchitecture • HIPAA Risk Assessment • Disaster Recovery Planning • Help Desk 2000 - 2003 2004 - 2008 $8 Million $10 - 12 Million

9. IT success depends on establishing a solid foundation to enable strategies and deliver expected outcomes & benefits Foundation for IT Success User focus is typically at the “surface” & on their own expected benefits User Benefits How well systems provide these benefits depends upon a solid, “below the surface” foundation Reliable Information Management Applications Systems Integration & Control Durable Infrastructure and Sound Standards Appropriate IT Leadership, Shared IT Vision and Road Map Skills, and Staffing Levels Senior Management Support, Joint-Ownership, and Communication of IT Strategic Vision and Plans Appropriate Context and Confidence Business Unit-wide Synchronization of Business Plans, Processes and Systems Clear and Sound Corporate Strategic Direction

10. Physician Practice Solutions Strategy Business Needs

11. Enhanced Business Performance Increased Collections Improved Patient Satisfaction Reduced Expenses Daily operations are not allowing physicians to focus all their attention on what they do best Treating patients Studies have shown that up to 70% of potential business performance improvements are driven by changes to organizational workflow on the "front end," or patient access component, of the revenue cycle. Operational Reality

12. Information About Patients Clinical Solutions Administrative Solutions Information About Care Goals of the Services

13. “Nothing will ever be attempted if all possible objections must first be overcome.”Samuel Johnson

14. The Brown & Toland View

15. Patient Eligibility & Benefit Plan Verification Direct Claims Submission & Contract Rate Verification Reconcile Patient Schedule with Charge Capture Increase Coding Accuracy Increase turnaround time for authorizations and Referrals - Rules Integrated Decrease Charting Time & Eliminate Dictation Cost Reduce Office Labor Decrease Record Storage Provide Greater Efficiency to Physician Groups

16. Network Efficiency & Cost Savings • Patient Information Available at the Point of Care • Network Diagnostic Results Reporting & Shared Data between Primary Care & Specialty Care • Eliminate Unnecessary Duplication of Diagnostic Testing • Increase Efficiency of Referrals and Authorizations • Improve Patient & Physician Satisfaction • Reduce Medical Errors

17. The Physician’s Input Focus Group Discussions and Interview Results

18. Interview Themes • Large demand for billing services – this will be a “quick win” with the physicians • Critical to articulate the ‘preferred cost structure’ and specific benefits to be gained by optioning BTMG’s services • EMR is essential to recruit younger physicians but will be resisted by older physician population that is less computer savvy • Will need ability to deploy EMR modularly due to variances in adoption and practice preferences • Contract with EMR vendor will need to be “staged” for growth • EMR will support P4P reimbursement criteria • Reliability is key – a lot of dissatisfaction with current systems and vendor support • Inefficiencies are prevalent in practices

19. Interview Themes • Common systems (especially PPMS) is a huge benefit – can draw from a larger pool of experienced staff • Several practices are ‘already looking for new systems’ • New systems must be ‘physician friendly’ and easy to deploy • Physicians will need to overcome residual mistrust of BTMG from previous de-install of PPMS • System needs to be ‘underwritten’ by BTMG (hardware, software, communications) • Must be a ‘good deal’ (less cost and more efficient) and a it imperative that the benefits are clearly articulated for buy-in • Data conversions from existing PPM systems will be needed • Resistance to EMR from older physicians expected • Resistance to PPMS from entrenched billing managers expected

20. Key Functional Priorities Based on the stakeholder interviews the following key functional priorities emerged: • EDI billing • Contractual variances • Insurance follow-up • Tracking status of payments • Effective date for co-pay • “Bubble forms” for charge capture • Flexible A/R reporting • Collections module • Multiple payor types/PPO products • Contact capitation • Using claims data for clinical research and assist with disease mgmt Billing & Reporting Scheduling • Flexible scheduling features • Scanners for insurance cards • Link with prior authorization • Results reporting • Workflow (refills) • ePrescribing w/formulary • Ease of charge capture • Note entry • Voice recognition • Disease management • Drug interactions • Health maintenance • Problem lists • HEDIS measures • Guidelines • Clinical reporting , e.g. lipid values Electronic Medical Record

21. Physician Practice Solutions Strategy System Selection

22. Lab • Radiology • Pharmacy • PT Ancillary Services • Eligibility Management • Care Management • Claims processing • Capitation management • General financials • Decision support • Internet • Member view of clinical record • Personal disease management • Self help • General Health Information Patient Education Administration Patient Intervention Patient Advocacy • Case management • Concurrent review • Wellness management • Preventive management • Disease management • Customer service • PCP assignment • Demand management • Credentialing Medical Knowledge Patient Access • Scheduling Online • Nurse advice • Physician access • eOffice Visits • Rx Renewals • Protocols • Pathways • Medical policies • Practice guidelines • Clinical decision support • Alerts & Reminders • Journals Population Management Medical Delivery • Primary care • Specialty consulting • Acute • Post acute Research & Education • Outcomes • Best practices • Research • Patient centric • Accessible services • Patient & MD is known to system • Care & care management is coordinated across the continuum • Clinical & administrative data is accessible enterprise-wide • Consolidated financial processes • Enterprise-wide reporting with “feedback loops” • Support for wellness and knowledge transfer to patient Core Medical Group Characteristics Brown & Toland Medical Group Characteristics

23. ConductVendor Workshop Develop Demo Scenarios & Scoring Methodology Begin Contract Negotiations Evaluate RFP Responses & Determine Leading Vendors Detail Vendor Demos & DetermineVendorFinalist(s) Conduct Finalist(s) Due Diligence(Site Visit/Ref.Calls) Vendor ofChoiceRecommend-ations Project Initiation& Kick-off Develop & Analyze Requirements FinalizationandDistributionof the RFP DevelopImplementationPlan Core Core Part Core Core Part Core Approvals Key Part = Client = Participants = Narrowing Points Core = Core Team Manage Expectations and Vendor Communications Vendor Evaluation Process

24. BTMG Guiding Principles Based on the stakeholder interviews the following guiding principles emerged:

25. Technology & Vendor Options • A:Single Vendor Solution • PPMS/MCA/EMR • Single patient-centric database • B: Hybrid Solution – multiple vendors • IDX MCA • Interfaced to PPMS/EMR • Other Vendor • PPMS/EMR • Single patient-centric database • C: Hybrid Solution – aligned vendors • IDX PPMS/MCA • Single patient-centric database • Allscripts EMR • Interfaced to PPMS

26. Brown & Toland Solution Patient Financials EMR Access Management Suites • Master Patient Index • Scheduling • Visit Management • Eligibility Verification • Referrals • Authorization • Self-Service Web Portals • Advance Benefit Notice • Ambulatory Payment Classification • A Single Financial Solution • Claims Editing Software • Combined business Services • Risk management • Charge Capture • Clinical Results • E-prescribing • Scan • Order • Dictate • Transcribe • Document • Workflow Applications TECHNOLOGY FOUNDATION Delivers operational benefits across the organization BTMG will also provide sophisticated reporting systems for physician use

27. Physician Practice Solutions Strategy Implementation Overview

28. Implementation Imperatives • Solidify Early Adopters • Flexible Critical Path • Resource Management • Enterprise Alignment

29. Enterprise Model Sharing InformationA Major Decision

30. Clinical Results Reporting • November 1, 2004 Go Live • LabCorp • 320 of 700 Physician Agreements in place • Next Steps • Additional Training Sessions – increase adoption • Additional Lab Vendors • Radiology Results

31. Clinical Results Reporting – Lessons Learned • 1 Physician : 2-3 Staff • Flexible Training Timetable & Approach • HIPAA Privacy Regulations • Lab Vendors • Physician Offices • Building Trust & Buy In

32. Full EMR Adoption • Focused on early adopters • Slow ramp up • 25 Physicians by end of 2005 • Build to core group over 2-3 year period • Use experience and success of early adopters to move late adopters

33. Full EMR Adoption – Lessons Learned • Demand greater than expected • Larger groups appear to be early adopters although more interest than expected from solo practitioners • Investment in experienced and focused deployment team has been invaluable in working through implementation issues and process changes • Modular approach will facilitate adoption • Physician champion in each office

34. Physician Practice Solutions Strategy In Summary

35. Physicians Physician Services Strategy PPMS EMR Patient BTMG BTMG’s IT Strategy Supports Key Business Drivers • Physicians have not invested heavily in technology • Physicians have not recognized ROI with existing systems • Physicians have not had solid, coordinated IT Support • Improve practice’s financial health through improved billing and reimbursements • Strengthen ability to provide high quality care through the use of solid IT systems • “Known” to BTMG throughout the enterprise • Improve quality of care through patient-centric view of health record • Need to recruit younger physicians • Strengthen medical management • Manage costs of care delivery through improved access to clinical data and use of best practices • Recognize revenues from P4P through technology deployment • Expand services to better meet business needs of BTMG physicians

36. Three-Step Approach Activities to Occur in Parallel Focus Groups • Establish functional & technical focus groups to perform detail due diligence • Provide education on the features/functions offered with PPMS & EMRs • Conduct survey to determine key drivers for physicians • Define key functional requirements and technical environment • Define specific benefits to be achieved with the new software and BTMG’s services Due Diligence • IDX / Allscripts to provide BTMG with formal proposals: • To support proposed modules & implementation approach & timing • Detail bid based on specific sizing & staging of roll-out • Conduct several reference calls to comparable vendor clients to discuss support, training, implementation and overall satisfaction. Implementation Planning & Contracting • Develop overall cost of ownership and revenue model for software and services • Refine implementation approach and roll-out plans • Determine key negotiating points and strategy • Conduct negotiations

37. Minimize Risks • Setting expectations is critical • BTMG offering “will need to be better and cheaper than what I have today” • Ownership of “data” (especially clinical data) may present concerns over loosing control of their practices • EMR Adoption • Older physician population may not embrace new clinical technologies • Contracting for “best price” but unknown participation will be a challenge • Clear requirement for modular implementation to address various levels of interest

38. Implementation Challenges • Education is a MUST!!! • Identifying a broad but focused group to drive implementation efforts will be critical • Variability of practices will cause challenges with setup and maintenance of systems • Process redesign will become a necessary component of improvements and may be resisted • This will be more evident in EMR deployment • Recognize and accommodate for go-live ‘slow downs’ and reduced productivity

39. “Nothing will ever be attempted if all possible objections must first be overcome.”Samuel Johnson