“Physician Office Issues : Why and How to Implement HIT in Physician Offices”

1. “Physician Office Issues: Why and How to Implement HIT in Physician Offices” Dr. James S. McIlwain

2. Objectives • Identify “Meaningful USE” and incentives to EHR implementation • Discuss the current Mississippi Health Information Exchange (HIE) demonstration project and other state initiatives • Describe why and how to implement an EHR in your practice

3. U.S. Healthcare Problems:Drivers of Change • Highest per capita health care spending • Ranked 37th of 191 in quality* • Threatens affordable care – 46 million currently uninsured – 71% of uninsured adults are employed full-time • $2T (2005) $4T (2015) – Increasing % of GDP * World Health Organization Data, 2000 (http://www.who.int/whr) Figure from: www.cbo.gov/ftpdocs/89xx/doc8948/01-31-HealthcareSlides.pdf

4. What Is HIT/HIE? Health Information Technology/Health Information Exchange Computers and other devices used to create a communications network for moving health information Exchange-connection of HIT

5. Benefits of Health Information Technology (HIT) • Comprehensive, timely management of medical information at the point of care • Secure exchange of medical information between health care consumers and providers • Disease registries/reporting and analysis capabilities • Public Health alerts - rapid detection and notification of disease outbreaks

6. Benefits of Health Information Technology (HIT) • Creation of a better work environment • Decreased : • Paper work • Costs • Errors • Duplicate tests and procedures

7. HITECH Funding for HIT & HIE Infrastructure New Incentives for Adoption Funding for Health IT • New Medicare & Medicaid paymentincentives for HIT adoption • $23 billion in expected payments from Medicare to hospitals & practitioners thru 2016 • $21 billion in expected payments from Medicaid through 2021 • ~$44 billion expected outlays • $1.2 billion for loans, grants & technical assistance for: • Regional Extension Centers ($640M) • Workforce Training ($80M) • Research and Demonstrations • EHR State Loan Fund Funding for HIE Community Health Centers $1.5 billion in grants through HRSA for construction, renovation and equipment, including acquisition of HIT systems • $564 M for Statewide HIE Development • States receive between $4 and $40 million $220 M for “Beacon” Community Program • 15 HIEs to receive between $10 million and $20 million Broadband and Telehealth $4.3 billion for broadband & $2.5 billionfor distance learning/ telehealth grants

8. Health Information Technology • Workforce Development $120 million from the ONC for health IT Minimally functional EHR: 20% physicians; 10% hospitals Shortfall of 51,000 qualified HIT workers over the next five years ONC, in collaboration with the NSF, DOE, and Department of Labor have developed HIT workforce programs to reduce the shortfall by 85% Programs focus on training HIT professionals, HIT research, & expanding adoption and use of EHRs

9. Statewide Health Information Exchange Nationwide Health Information Exchange Regional and Local Health Information Exchange Rationale - States as Fulcrum to Harmonize Local and National Efforts • Address statewide • barriers to HIE • Balance the rights and • needs of all residents • Act as a bridge between nationwide, • regional, & local HIEs • Serve as a conduit for consensus on and adoption of standards • Serve statewide goals for health care quality and cost-effectiveness • Provide sufficient level of data and transactional data aggregation to leverage public/private investments

10. ONC’s State HIE Program • Goal: Plan and develop the HIE infrastructure to ensure: • Widespread interoperability across entire state • Providers and hospitals can achieve meaningful use Required Plans “Domains” to Address Types of Exchange • Eligibility & claims transactions • eRx & refill requests • Lab ordering & results delivery • Public health reporting • Quality reporting • Rx fill status and/or med fill history • Clinical summary for care coordination & patient engagement -Strategic Plan: State’s vision, goals, objectives and strategies for statewide HIE; including plans to support provider adoption -Operational Plan: Detailed explanation, targets, dates for execution of strategic plan • -Governance • -Finance • -Technical infrastructure • -Business & Technical Ops • -Legal and Policy

11. Status – Estimates of Statewide HIE Efforts Planning efforts launched Planning efforts underway, strategic plan in development Strategic plan completed, progressing to implementation Framework for statewide HIE completed, operations begun

12. MSCHIE

15. 4 4 12 10 12 11 2 2 7 3 1 11 2 6 11 6 9 1 1 2 11 11 2 9 2 5 6 8 13 6

16. Project Implementation • Governor’s Task Force Created: • Proof of concept project serving as the core foundation for statewide implementation • Grant received for pilot project on the Mississippi coast that was affected by hurricane Katrina • Grant Administration and Contracting: • Information & Quality Healthcare (IQH)—the Medicare Quality Improvement Organization for Mississippi • RFP Procurement Process IQH/ITS • Awarded to Medicity of Salt Lake City, Utah

19. “This should be called an ‘Health Improvement Exchange’ instead of Health Information Exchange! WOW!

20. The Push to Meaningful HIT Use • There is an evidence base showing that the right combination of HIT and institutional culture can lead to important gains in quality and value = Health Care Delivery Reform • The U.S. needs these gains so desperately it is willing to bet on EHRs • Used appropriately, health IT seems so likely to improve quality that we should use it now

21. Broad Goals for Meaningful Use Vision Enable significant and measurable improvements in population health through a transformed health care delivery system. Goals Improve quality, safety, efficiency and reduce health disparities. 2. Engage patients and families. 3. Improve care coordination. 4. Ensure adequate privacy and security protections for personal health information. 5. Improve population and public health.

22. The HITECH Act’s Framework for Meaningful Use of Electronic Health Records (EHRs)

23. Programs - Build, Expand, Demonstrate MUState & Regional Efforts will Lead the Way

24. Meaningful Use Overview Statutory Framework: In HITECH Act, Congress established three fundamental criteria of requirements for meaningful use: 1. Use of certified EHR technology in a meaningful manner. 2. Certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality and coordination of care. 3. In using certified EHR technology, the provider submits clinical quality measures and other measures by the secretary.

25. Incentive Payments Medicare Medicaid

26. Who is eligible? Medicare Doctor of medicine or osteopathy Doctor of dental surgery or medicine Doctor of podiatric medicine Doctor of optometry Chiropractor › Medicaid Physicians Dentists Certified nurse-midwives Nurse practitioners Physician assistants practicing in an FQHC or RHC that is so led by a physician assistant

27. Medicare Incentive Payments

28. Medicaid Incentives to EHR implementation As noted, EHR-related incentives reflect 85 percent of the net average allowable costs for certified EHR technology. The maximum payment schedule for office-based physicians or practices that have at least 30 percent Medicaid volume is as follows: • Year 1: $21,250 • Year 2: $8,500 • Year 3: $8,500 • Year 4: $8,500 • Year 5: $8,500 • Year 6: $8,500 Total= $63,750

29. Medicaid Incentive EP’s Entity Minimum Medicaid patient volume threshold Physicians 30% Pediatricians 20% Dentists 30% CNMs 30% PAs 30% NPs 30% Acute care hospitals 10% Children’s hospitals No requirement Needy individual patient volume threshold EP practices in an FQHC or RHC 30%

30. 9 Medicare Medicaid › $44,000 › HPSA 10% bonus › No minimum # of patients› No mid-levels › Calculation: 75% of submitted allowable charges by doc, up to cap for the year › First year of program is 2011 › Penalties for non-compliance› All external funds okay › $63,750 30% threshold; 20% for peds› NPs, NMWs; Pas if lead provider in a rural health clinic › No calculation based on fees – flat payment intended to offset purchase of the EHR and can collect in 2010 if State is ready › No penalties (yet!) › Stark $$ or Fed grants may lower payment

31. Welcome to 2010 . . . THE YEAR OF THE EHR

32. Electronic Health Record Implementation

33. Results of MGMA Study 1.The study identified 285 practices where EHR implementation is in process or is fully implemented. Over 76% of the adopters report that they are satisfied or extremely satisfied with their EHR system and over 66% report that they are satisfied or extremely satisfied with their EHR vendor support. This indicates that adopters are more satisfied with their actual systems than with their vendor support of those systems. 2. Much hard work and planning is required to enhance the probability of a successful EHR implementation. 3. Most practices should expect increased operating costs, reduced productivity, and other assorted surprises and challenges during the first 6 to 24 months of the implementation. 4. After the first 6 to 24 months, the benefits of EHR adoption should increasingly exceed the costs, and most practices will wonder how they ever conducted business without an EHR.

34. Potential EHR Benefits (continued) 3. Increased practice productivity a. Automatic generation of prescriptions, lab reports, and letters b. More efficient phone triage due to immediate access to patient record c. Critical review and revision of work flow leads to increased efficiency. d. Increased provider productivity due to increased staff productivity 4. Elimination of paper files frees up space for other uses a. Space can be used for new examination rooms, improving patient flow b. Space can be used for new revenue generating ancillary services 5. Increased practice revenue a. Better E and M documentation enhances provider confidence to code and bill appropriately for services rendered b. Improved charge capture c. Reduction in delays in billing activities d. Reduction in payer denials • 6. Increased quality of patient care • a. Improved continuity of care and preventive care • b. Improved chronic disease management

35. Potential EHR Benefits (continued) 7. Increased patient safety a. Patient record available 24/7 in order to respond to emergencies b. Ease of accessing patient prescription information in case of drug recall c. Increased safety in prescribing due to drug interaction and allergy alerts 8. Increased patient satisfaction a. More rapid processing of prescription orders and refills b. More rapid reporting of lab results to patients c. More rapid response to patient phone calls and questions d. Reduction in cost to patient by reducing need for duplicating radiology and lab tests 9. Increased staff job satisfaction a. Reduced staff stress related to failed searches for paper records b. Process of EHR implementation creates

36. Potential EHR Benefits (continued) 10. Increased physician satisfaction and quality of life a. Ability to complete charts before going home or in comfort of home b. Reduced need to do dictation after seeing a patient c. EHR can be a benefit in recruiting new physicians 11. Increased referring and consulting physician satisfaction a. Enhanced ability to quickly generate letters to physicians b. Enhanced ability to share radiology and lab results with physicians 12. Increased quality of the health record a. Record is legible and timely b. Record is more consistent across different providers c. Record is more defensible from billing perspective 13. Integration with other systems and facilities a. Interfaces with lab and imaging equipment automatically incorporate data into the health record b. Interfaces with hospitals and surgery centers enable health record data to be shared by authorized providers

37. Potential EHR Benefits (continued) 14. Increased ability to query the data base and conduct data mining activities a. Ability to track outcomes and participate in pay for performance programs b. Ability to monitor and benchmark quality of care c. Government and public health reporting is easier d. Diagnosis registries easier to maintain.

38. Potential Unsatisfactory Outcomes from EHR Adoption “A general theme from the adopters is that it simply takes a year or two to learn how to rectify the adverse outcomes, particularly in practices that did not conduct critical work flow analysis prior to implementation.” 1. The EHR does not live up to the practice's expectations. a. Practice has difficulty in setting up the EHR system, data capture methods, and data input templates to fit the needs of different provider and specialty work styles and patient conditions. This leads to inconsistent use of the system and inconsistent data in the EHR. b. Specialists in multispecialty settings often want features that are not available. c. Practice does not recognize need for certain features until after implementation begins. d. EHR creates new work flows that are hard to implement.

39. Potential Unsatisfactory Outcomes from EHR Adoption (continued) (1.) e. Practice is unable to eliminate paper records. f. Long time period is required to get up to speed. g. Expectations were that EHR would be easier to use. h. Physicians are unable to reduce dictation and use features of the EHR. i. The EHR software has an unacceptable level of flaws and bugs. 2. Practice staff and physicians experience increased frustration and stress. a. Some physicians (often older physicians) have difficulty in learning how to use the system. b. Some physicians and staff are intransigent and refuse to use the system. c. EHR use has adverse impact on staff interaction and communication. d. Physician satisfaction decreases due to extra time spent learning and using the EHR.

40. Potential Unsatisfactory Outcomes from EHR Adoption (continued) 3. Practice productivity decreases. a. Physicians devote more time to using the EHR system after the patient visit. b. Additional workload and documentation is shifted to physicians. c. Too many template screens are required to document a visit. d. Software updates require new things to learn on continual basis. e. Unanticipated time and cost are required to scan old medical records. f. Too much time is devoted to abstracting old records to the new database when a scanned image will suffice. g. Staff is unable to effectively search for scanned information. h. Practice sees fewer patients during initial implementation. i. Productivity drops when system goes down. j. Practice unable to find temps and subs who know how to use the EHR. 4. Practice costs increase. a. Information technology staffing, salaries, and oversight costs increase. b. Staff overtime costs increase. c. Practice adopted too early, before some hardware costs had decreased. d. Practice underestimated costs of continual software and hardware upgrades, malware protection, and security protocols.

41. http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=21086

42. Regional Extension Centers (REC) Provides education, outreach and technical assistance to select, successfully implement, and meaningfully use certified EHR technology

43. Regional Extension Center (MS) Grant applications for the REC will be awarded in two cycles: • Cycle one announced February 12, 2010 (32 awardees) • Cycle two (MS) should be awarded at the end of March 2010

44. Regional Extension Center • Target settings: • Individual and small group primary care practices (10 or less providers) • Public and Critical Access Hospitals • Community and Rural Health Centers • Other settings that predominately serve uninsured, underinsured, and medically underserved populations

45. Regional Extension Centers (MS) Project Goal: • 1000 of the 2,253 Mississippi priority primary care providers located in the state will be recruited to adopt, implement, and meaningfully use HIT within the first two years of the four year project

46. Functions of the Regional Extension Center • Provide Education and Outreach to Providers: • The Regional Center will provide for dissemination of knowledge about the effective strategies and practices to select, implement, and meaningfully use EHRs • The Regional Center will become, upon award, a member of a consortium that will be facilitated by the HITRC. • Provide on-site technical assistance as a key service offered by the Regional Center to priority primary-care providers, who are: • Physicians and/or other health care professionals with prescriptive privileges, such as physician assistants and nurse practitioners • Individual and small group practices primarily focused on primary care; Community Health Centers and Rural Health Clinics; and other settings that predominantly serve uninsured, underinsured, and medically underserved.

47. Functions (continued) • Provide comprehensive support for providers to achieve meaningful use. • Help providers achieve, through appropriate infrastructure, exchange of health information in compliance with applicable statutory and regulatory requirements, and patient preferences. • Participate in local workforce development projects and with community colleges to provide expanded career pathways in information management and technology in health care. • Provide knowledge of privacy and security best practices for dissemination of personal health information. • Construct a collaboration to obtain vendor evaluations and arrange optimal group purchasing offers.

48. What You Need to Do

49. Electronic Health Record Implementation Contract with the Mississippi Regional Extension Center– 90% of the expenses for these services will be paid for using this resource for 2010-2012 if you are a priority primary care physician in Mississippi!

50. That is my final answer! Any questions? jmcilwain@msqio.sdps.org