I. Funding sources: FCHD receives support from the following:

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1 Practice Management & Electronic Health Records Cost Benefit Analysis 2014 Public Health has unique requirements for conducting and reporting on its services, as well as maintaining compliance with several federal regulations for operations and patient rights. Public health must be responsive to federal and state legislation and various funding sources. This paper was developed to provide an overview of regulatory, funding, and management organizations along with the current benefits and limitations of staff and technology support for operations. I. Funding sources: FCHD receives support from the following: County Property Tax revenue State grants (i.e.; Formula, Maternal and Child Health, Child Care Licensing, Immunization Action Program) Federal pass-through dollars (i.e.; Maternal & Child Health, Family Planning, WIC) Fee for Service income from public insurances ( i.e.; Medicare, Kan-Care, TriCare) Fee for Service income from private insurances ( i.e.;blue Cross/Blue Shield, Coventry, Aetna, United) Fee for Service income from local business (i.e.; Schools, Cities, Private business) Fee for Service income from state programs (i.e.; Farmworker Program, TB control) Private donations Private Grants Miscellaneous activities and reimbursements II. Regulatory Requirements: Clinical and Employment regulations for FCHD include: III. OSHA HIPPA Vaccines for Children Nurse Practice Act Specific Grant requirements Disability-handicap accessibility Quality Assurance Programs Contract Requirements (timely filing, etc) Licensures (laboratory, pharmacy, nursing etc.) Elective compliance Public Heath Accreditation

2 Current on-line reporting and data entry Immunization Registry CLARIS Child Care Licensing Dispense Assist (Emergency dispensing of medications) EpiTrax (Disease investigation and tracking) Maternal/Child Health encounters no reporting available Manual (paper and electronic forms) reporting and data entry Family Planning Sexually Transmitted Disease Grant reports and affidavits Financial software Quick books What is expected in the near future PHI exchange Private health information exchange Patient access to records (Care connect) Current opportunities?? Meaningful Use Medicaid/Medicare Practice Management Software For the last five years, FCHD has used Quickbooks to track patient accounts and provide basic revenue tracking, open balances and expenses. This was a significant improvement over paper and pen ledgers that were maintained prior to Before Quickbooks, staff would manually calculate sliding fee scale discounts and record fees on both family planning financial records and in the department ledger. All entries for unpaid bills were found by manual review and revenue totaled with a calculator. With Quickbooks, open balance reports, profit and loss reports and individual patient accounts could be managed. A limitation of Quick books has been the inability to easily track third party payments and create systems for patient quality outcome data. It takes considerable manipulation to identify third party payer amounts by class for state grant reports and must be checked against deposits made to the treasurers office by hand at this time to be considered accurate. A different breakout is necessary for quarterly reports to the commission. Structured data includes indicators used to evaluate services and patient outcomes. Payers and state and federal partners increasingly demand this data. Beginning in , the health department began billing private insurances in addition to Medicaid and Medicare. This increased revenue along with workload. FCHD was one of only three in Kansas to begin billing private insurances; one in two

3 with a professional coder on staff. In order to fund the insurance coder position, the administrator absorbed the preparedness grant activities (.5 FTE) when that position became vacant. Private insurance billing is now considered a best practice for health departments and future sustainability as well as expected by Funders. All insurance billings must be pulled from the invoice manually and reentered into the HCFA forms and uploaded to the transmission service (PC Ace) to be sent to insurance companies. All insurance payments as well as other payments are posted manually into Quick books. We have been able to add fields for data and modify the system enough to maintain patient information, but it is cumbersome and not all screens can be modified to place data that can be pulled into reports appropriately. Quickbooks also allows us to add discounts as required without manual calculations when we bill, but the level for billing is still figured manually. In the technology age, not only is efficiency a focus, but funders, public health and medical practice in general require quality assurance practices be in place. Quality assurance manages patient and practice data in a manner that allows for reporting, comparison and improvement. For example, quality assurance data reports for the access clinic include a patient count of controlled hypertension at last visit. This means we pull all access charts and review them to see if at the last visit hypertension was controlled. Another missing piece is appointment scheduling. Currently we use a share Microsoft calendar that limits viewing by unapproved staff. However, HIPPA security regulations are minimally met as we cannot track all entries in either this system or quick books. In other words, who is looking at the data and can we be sure they have approved access. The cost-benefit table below outlines some of the reasons for purchase and implementation of PM/EHR software.

4 Current Operations Weakness Solution Benefit Scheduling Staff time tracking Billing and payment receipt HIPPA security Use MS Outlook. Not integrated with other systems Best guess, reliant upon staff noting time for each client/grant; not reliable Entered into system from paper notes, payments manually entered into patient account from EOB Provides integration with medical records; records the staff assigned to client to view openings or conflicts Staff contact w/patient is recorded each time they enter the system; HIPPA compliance; grant reporting Information pulled into billing with codes assigned based upon nurse entry. Sliding fee scale added automatically. History for client held in system. Some systems will have automatic conversion for ICD 9 to ICD 10 Patient names would not be recorded in a system that is shared with other county departments(hippa security, time conflict management) Potentially grant funds if audited federally and not found to be sufficient time accounting. Example, software will record actual time provider spends with patient and in record. Now it is an estimate written down on paper. Estimated to reduce staff time by.5 1 FTE; allows for more timely work freeing staff time for additional review and auditing of accounts. Decrease rejection rate on claims so fewer resubmissions. Estimates over 90% acceptance with software.

5 Families Patient charts Data entry Reporting No links between family members for billing purposes or parent authorization. Each reviewed individually Paper charting results in legibility issues and misplaced charts One patient s info may be entered into up to five different systems Reports to the state are created from a variety of data sources since all the information cannot be gathered from our QuickBooks database. Family planning data is submitted on paper for every client visit. Families linked; allows for name changes and search function for lost clients (those who changed their name or gave different name or misspelled name) Software reduces paper use, copies, and archiving space. Charts are more easily found through search functions if a name changes. PM/EHR creates one record from which all other systems pull data. Interfaces are or can be developed for data transfer to WebIZ, PCACE, Laboratories, etc. Report templates specific for public health are built in and all data elements can be pulled for special reports as needed. Reduce or eliminate duplicate charts under different names and search time for paper chart by staff. Save staff time (approximately 200 hours /year ) Office supply reduction = Appx $ Reduced staff time for duplicate and triplicate entry Estimate a reduction from hours to prepare a commission report to 3-5 hours. State report accuracy improved and confidence in the report improved (third party billing X grant

6 Quality Assurance and structured data E-Prescribe CMS requirements Health Information Exchange/Patient access We must manually pull data from paper charts to review for adherence and to track quality measures. Some data is just not available Provide written script when not filled in our pharmacy. Our pharmacy records are held and entered in three places to obtain the tracking, labels and data required. Requiring electronic records and quality data Pull individual charts, copy, fax or mail. May have to hunt for chart depending upon its place in use Compliance with grants reporting and insurance quality assurance measures. (ACCESS and family planning especially) Prescriptions directly in patient s file, inventory tracking by lot number based on automatic detriment when order filled. Cost updated and historical cost of previous lots held in the system. Easier to respond to recalls. Will probably be an issue for public health in the future. Can always access chart and print or whatever is requested. Meeting new grant requirements and a way to create quality improvement for patients and our facility Correct price assigned to any given medication based upon purchase price (we bill Medicaid only what we pay for a medication). Inventory updated continually. Time saved: hours/year ($400.00)

7 HIPPA HIPPA regulations have tightened further and with significant fines for breach of confidentiality. Some of the rules we have trouble meeting include verifying who is looking at a chart, password protection, secure data backup daily. Cloud based system has double back ups for recovery, and must meet HIPPA security regulations. Potentially thousands if we had a breach NOTE: Meaningful Use and HITECH: An excerpt from the Federal Register, July 28, 2010 in regard to the HITECH Act for which I was informed we could qualify and now question. ONC issued an interim final rule with comment for the standards and certification criteria for certified EHR technology at the same time our proposed rule was issued. After reviewing the comments they received and to address changes made in this final rule, ONC will be issuing a final rule in conjunction with this final rule. When we refer to the ONC final rule, we are referring to this final rule titled Health Information Technology: Initial Set of Standards, Implementation, Specifications, and Certification Criteria for Electronic Health Record Technology. When we refer to the ONC IFR, we are referring to the interim final rule with commend period published in the Federal Register on January 13, SMILE