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Selecting and Implementing a Meaningful EHR System. Speakers. David Groves, HealthBridge Executive Director, Tri-State Regional Extension Center Mary Zile, Director, Practice Consulting, Tri-State Regional Extension Center. Overview. Many Good Systems - PowerPoint PPT Presentation
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HealthBridge is one of the nation’s largest and most successful health information exchange organizations.
Selecting and Implementing a Meaningful EHR System
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.
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.
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
Overview
Qualifying Vendors
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 .
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
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
Differentiating Factors
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 .
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 Fit for your practice
Feature / Functionality REC Importance*
EMR SystemWork Flow / Efficiency 18Display / Navigation 17Data Input / Structure 16Rx Module 15Interoperability / Results 14Quality Reporting 13Clinical Support 11Document Management 10Patient Portal 9PM & EMR SystemsImplementation / Training 12Application Support 3IT Infrastructure 2PM SystemWork-Flow Management 7Self-Pay Collections 5Alerts / Messaging 6R/C Reporting 8Edits / Claim Scrubbing 4EDI / Clearinghouse 1
*18 = most important / 1 = least important
Soliciting Vendor Bids
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 .
Request For Bid (RFB)• Gather information and
understand each vendor’s functionality
• Rate the contenders against your Differentiating Factors
• Use an objective scoring methodology
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 .
Standardized Format• Enables head-to-head price
comparison• Roll everything up into 5-year
grand totals for:• Software• Services (e.g.
implementation)• Hardware
Compare “Apples to Apples”
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 .
• Use 5-Year Totals for Comparison
• Eliminate Vendors that Don’t Fit Your Budget
• Lowest Cost/Point may be your Best
Value
Vendor:
Vendor #1
Vendor #2
Vendor #4
5 Year Software Costs $ - $ - $ -
Total Services Costs $ - $ - $ -
5 Year Hardware Costs $ - $ - $ -
5 Year Grand Total Costs $ - $ - $ -
Total Points on Vendor
Comparison - - -
Total Cost per Point
(Best Value) $/pt. $/pt. $/pt.
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 .
• 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
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 .
“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 would Quality be effected?• Would there be an impact on Revenue?
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 .
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?
Informed 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 .
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
Total 5-Year Cost 229,000$ 225,000$ 195,000$
Cost per Point 190$ 201$ 191$
Grand Total Points 1206 1122 1019Demo Scores 390 370 400
Site Visit Scores 300 280 250
Reference Scores 80 90 70
Total Matrix Scores 436 382 299
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 .
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.
Implementation OverviewThe 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.
Collaborative Implementation PlanStart 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.
Technical AssessmentWhat 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.
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.
SoftwareLessons 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.
HIE connectivity is a major component of Meaningful Use alignment and offers an “early victory” in efficiency gains for the practice
Health Information Exchange
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.
Quality ReportsThis 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.
Data ConversionThe 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.
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.
Patient / Practice
Communication
Let your patients know what is going onAsk for their patienceLet your patients know what is going onAsk for their patience
Training
Important phase – don’t miss itTesting / Simulation
Chart Abstraction & Pre-Loading
Go - Live Massive resources at go-liveBig Bang or ease into it?Cut the schedule?
Re-Assessment & Follow-Up Circle backProductivity ramped up to baseline?Anybody struggling?
Timing is importantBe careful what you pre-loadPre-loading is a form of training
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 .
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 .
• 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 access to 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 safety are hallmarks of the medical home and Physicians in the practice accept accountability for continuous quality improvement
Joint Principles of PCMH
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 .
1. Enhance Access and Continuity: Accommodate patient needs with access and advice during and after office hours; provide patients with team-based care
2. Identify and Manage Populations: Collect and use data for population management
3. Plan and Manage Care: Use Evidence-based guidelines for preventive, acute and chronic care management.
4. Provide Self Care Support and Community Resources – Assist patients and their families in self-care management with information, tools, and connections to community partners
5. Track and Coordinate Care: Track and manage referrals, care transitions, and clinical results.
6. Measure and Improve Performance: Use data to continuously measure and improve care quality and patient experience.
PCMH Recognition Standards
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 .
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 .
Value-Driving Elements of
Patient Center Medical Home and Accountable Care
Organizations
1. Enhanced Access2. Better Care
Coordination3. Better Health IT4. Payment Reform for
Primary Care
Donald M. Berwick, MDAdministratorCenters for Medicare and Medicaid Services
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.
Source: Better to Best Report - Value-Driving Elements of the Patient Centered Medical Homeand Accountable Care Organizations, March 2011
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
PCMH 2011 and Meaningful Use
1. Electronic Prescribing2. Drug Formulary, drug-drug,
drug-allergy checks3. Maintain active problem list
and current diagnosis and meds
4. Record patient demographics including race, ethnicity and preferred language
5. Record and chart changes in vital signs
6. Record smoking status7. Report quality measures8. 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
Meaningful Use Requirement Found in PCMH Standard
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
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 .
This presentation will be posted at: TriStateREC.org
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 .
Objective Scoring Tool
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 .
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
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 .
Q#
Feature / Functionality
Fully Available
& Supported
Partially Available /
Future release
Not Available
Not planned
Comments
DM1 Scanning/faxing application integrated within the EMR
DM2 Ability to annotate, mark-up and sign scanned documents
DM3 OCR capabilities that facilitate querying / searching scanned documents
DM4 Ability to fax documents directly from the EMR
2 points each 1 point each Zero
points
Sub-Totals 0
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 .
Points Feature / Criteria Comments
DM5 Provide an overview of the scanning/indexing process and the practice resources / time commitment required.
DM5 Response:
DM6
Specify processing times (pages per second) for: Scanning Uploading Image Retrieval
DM6 Response:
DM7 Describe image storage considerations, i.e. location, security, uploading/retrieval, memory requirements, cost, etc.
DM7 Response
Document Management Total Points
Importance Factor
Total Category Score
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 .
Total Matrix Scores 436 382 299
EMR System 212 188 127Work Flow / Efficiency 27 18 9Display / Navigation 18 27 9Data Input / Structure 14 21 7Rx Module 30 20 20Interoperability / Results 27 27 18Quality Reporting 30 30 20Clinical Support 21 14 14Document Management 24 24 16Patient Portal 21 7 14PM & EMR Systems 78 78 69Implementation / Training 27 27 18Application Support 30 30 30IT Infrastructure 21 21 21PM System 146 116 103Work-Flow Management 21 14 7Self-Pay Collections 24 18 12Alerts / Messaging 30 20 20R/C Reporting 30 20 20Edits / Claim Scrubbing 21 14 14EDI / Clearinghouse 20 30 30
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 .
Software Item
3rd Party Product Name
(if applicable)
Total Practice One Time
LicenseFees
# of Providers
IF Fees are Per
Provider
Total Practice Monthly
Subscription Fees
(60 mos.)
Other Pricing Model* (5 Years)
Software Maint and
Support Fees (5 Years)
5-Year Total Software
Cost
$ - $ - $ - $ - $ -
Practice Management Sub-Totals $ - $ - $ - $ - $ - Modular Price $ -
Patient Demographics Included Included Included Included $ - Patient Insurance & Guarantor Data Included Included Included Included $ - Patient Scheduling Included Included Included Included $ - Accounts Receivable Management Included Included Included Included $ - Reporting and Business Analytics Included Included Included Included $ - Inventory Control Included Included Included Included $ - Online Help Included Included Included Included $ -
$ -
Vendor Name: Vendor Product: Vendor Point of Contact:
Software Grand Totals:
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 .
Service Item
Fixed Per Practice
One Time Charge
# of Providers
IF Chgs are Per
Provider
Time and Materials
Hourly Rate
Time and Material
Estimated Level of Effort
(Hours)
Estimated Time &
Materials (Plus Travel)
Costs
Estimated Total Services
Costs
$ - $ - 0.00 $ - $ -
Installation & Configuration Sub-Totals $ - $ - 0.00 $ - $ - Modular Price $ -
Provider Site Hardware Installation Included Included Included $ - Provider Site Software Installation Included Included Included $ - Network Connection and Configuration Included Included Included $ - Estimated Travel Expenses Included $ -
$ - $ -
PM System Implementation Services Sub-Totals $ - $ -
0.00 $ - $ -
Fixed Pricing Time and Materials Pricing
Services Grand Totals:
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 .
# Req'd Hardware / OS Item Specifications (brief) Total Practice One Time Cost
# of Providers
IF Fees are Per
Provider Other Pricing
Model*
5 Year Maintenance
& Support Cost
(5 Years) Total 5-Year
Cost
Hardware / OS Grand Totals: -$ -$ -$ -$ Data Center Data Center Sub-Totals: -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$ -$
Network Gear Network Gear Sub-Totals: -$ -$ -$ -$ -$ -$ -$ -$ -$
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 .
EMR
Demo Score Card
Intu
itive
Fu
nctio
nalit
y
Easy
N
avig
atio
n St
aff
Effici
ency
Pr
ovid
er
Prod
uctiv
ity
Enha
nces
Q
ualit
y En
hanc
es
Reve
nue
Poin
ts A
war
ded
Check All That Apply
= 5 points
Comments
Provider’s Schedule Patient Flow Monitor
Open Pt’s Chart Retrieve Recently Used Chart Review Patient’s Chart Demographics
Clinical Summary Labs / Flow Charts Med List Problem List Allergies Outstanding Orders MA/Nurse Documentation Vitals
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 .
Site Visit
Score Card EMR
Will
enh
ance
pr
ovid
er
Prod
uctiv
ity
Will
enh
ance
St
aff E
ffici
ency
Will
enh
ance
Q
ualit
y W
ill e
nhan
ce
Reve
nue
Poin
ts A
war
ded
Check all that apply = 5 points
Comments
Observe Patient Flow Check-In Exam Room Check-Out
Observe Documenting a Patient Visit Review Chart / Labs MA Documentation MD Documentation
Observe Phone Messages Triage Routing Tracking / “Close the Loop”
Observe Clinical Enhancements Coding Assistance Decision Support Clinical Rules / Protocols
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 .
Reference Score Card
EMR
Poor
1
Acce
ptab
le 2
Good
3 Ex
celle
nt
4
Not
Rat
ed
Poin
ts A
war
ded Check Only One
Comments Training Team
Knowledge & Skills
Overall Effectiveness
Time Commitment
Fulfilled what was promised
Implementation Team
Knowledge & Skills
Overall Effectiveness
Time Commitment
Fulfilled what was promised