ELECTRONIC HEALTH RECORDS: SO MANY OPTIONS!

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1 ELECTRONIC HEALTH RECORDS: SO MANY OPTIONS! Ann Michael, Ph.D., The University of Tennessee Health Science Center Kelly Pyle, Au.D., Illinois State University Cara Boester, M.A., Illinois State University

2 DISCLOSURE Ann Michael has no financial or nonfinancial relationships to disclose. Cara Boester has no financial or non financial relationships to disclose. Kelly Pyle has no financial or non financial relationships to disclose.

3 Ann Michael, Ph.D., The University of Tennessee Health Science Center

4 EHR vs EMR: What s the Difference? Electronic Health Records(EHR)- Same benefits as EMR and more. Comprehensive PHI data-across more than one professional practice, facility. EHR can move with the Pt. EHR tracks data and manages data for reports, audits, etc. Electronic Medical Records (EMR)- A digital version of a paper chart Contains pt. medical history from one practice Benefits: tracks data, monitors certain parameters (vaccinations, blood pressure); improves quality of care in practice

5 Defining Electronic Health Record (EHR) Personal Health Records (PHR) Electronic application used by patients to keep track of visits Increases Pt. involvement in their own care Can be standalone or connected to EHR systems through secure portal

6 Electronic Health Records (EHR)-History President Bush in State of the Union. EHR available to most Americans in 10 yrs. Goal to avoid medical mistakes, reduce cost, and improve care HHS Secretary appointed a national health information technology coordinator to provide leadership in developing IT infrastructure CMS defined their role in provision of EHR.

7 Electronic Health Records (EHR)-History 2009-President Obama in State of the Union. Invest in order to reduce errors, bring down costs, ensure privacy, and save lives Hitech Act signed into law. Hospitals ranked on 30-day readmission rate for heart attack, heart failure, and pneumonia. Financial consequences President signs Patient Protection & Affordable Care Act. Strengthened Hitech Act introduced Meaningful Use by 2014.

8 Electronic Health Records (EHR)-History Last 10 years-pilot projects. CMS implemented pilot projects with medical facilities Final rules for ACOs including financial incentives to rural docs and hospitals. Failure to report timely quality measure data could result in sanctions Ruling of Supreme Court

9 Benefits of EHR: Improve Pt. Outcomes EHRs Document & Manipulate Pt. Information: Reduce medication errors-monitor allergies in meds.; flags medication interactions Monitors timelines for screenings, evaluations, authorizations, goals; improve use of preventive care Legible Pt. notes Provides PHI including SLP, PT, OT, Audiological, & Psychological information across providers and facilities Presents big picture of patient disabilities and treatment across different clinics-different professionals

10 Benefits of EHR: Efficiencies & Cost Savings EHRs Create More Efficient Practices: Integrates scheduling systems; links appointments directly to progress notes, coding, & claims Reduces amount of time required for paperworkreduces duplication of forms to be completed Reduces duplication of testing; programed to send test results to multiple providers Employs alert systems for testing, signatures, timelines Enhances ability to meet regulation requirements (PQHR, Advanced Beneficiary Notice) Reduces lost of revenue

11 Benefits of EHR: Efficiencies & Cost Savings Reduces chart storage, and time re-filing. Improves coding accuracy and documentation results in better reimbursement Improved patient quality of care and pt. education Automated formulas for accessing information for quality measurement Access to Pt. information from numerous secure sites

12 How will Patient Health Information (PHI) be Used? Research Purposes Demographic information Develop Pt. registries for specific disabilities Billing Purposes Coding and accuracy in documentation Efficiency in conducting monthly, annual audits Patient Care Establish a Continuous Quality Improvement Strategy Monitors progress in multiple areas

13 Implementation of EHR System: Major area of consideration Privacy and Security Your practice and not the EHR Vendor is responsible for: HIPAA Requirements The Privacy Rule HIPAA security CMS Meaningful Use Requirements First priority includes risk analysis, action plan, & on-going risk management

14 I. Implementation: Establish expectations & customize technology to meet your needs Analyze and map the practice current workflow of your clinical practice Reassess workflow- consider how to increase efficiency Establish clinical and billing reports; forms, documentations and notifications; audits

15 Referral Contact Pt. by Phone: est. brief case Hx via phone Mail Case HX or Complete on-line: medication, registration form Notice to staff: Case HX not completed, or phone with second, final request. Services billed to insurance. ID insurance requirement No Required Authorization Schedule Pt with clinician, student, room, according to disorder/specialty Date of Service Pt/caregiver complete forms: NNP, release, consent, financial Evaluation completed: DX and Recommendations SOAP Note documents evaluation, signed, dated Physician authorization acquired & Pt. informed Cancellationreschedule No-show: Drop from process Notify referral source DX report forwarded to Pt, other agencies, referral source. Include Customer Satisfaction Form with envelope. Assessment Reports and Documentations: 1. Summary of Referral Sources 2. ID patients by demographics (define demographics) 3. Number of evaluations per clinician; per student-clinician; & per disorder over designated period of time. 4. Summary of no-shows and cancellations per Pt. 5. Flexibility in documentation of the evaluation template 6. Add DVD to evaluation report 7. Process for adding test forms, signature forms to chart with original data 8. Editing mode for all documentation until final signature. 9. Signals necessary signatures, dates for audit purposes. 10.Flags timelines for 11. Documents diagnosis-severity; prognosis; recommendations

16 Est. mode of communication , phone Complete forms on-line or in office SOAP Note documented, signed and dated Mail Customer Satisfaction Form or complete online Referral Obtain relevant HX, reports PT. attends sessions Signs all forms Schedule by disability with clinician, student-clinician, room Complete and Distribute Progress Report for End of period Ins. denied, inform PT and Referral Source Clinician Signature for Billing Preauthorization for insurance, Include # of sessions and timelines for progress reports, dates for next authorization Discharge Report Cancellation-reschedule 2 No-show: Drop from TX Session Billed Treatment Reports and Documentations: 1. Summary of Referral Sources 2. ID patients by demographics (define demographics) 4. Number of sessions, Number of noshows and cancellations per clinician and student-clinician. 6. Flexibility in report template 7. Add DVD to progress, discharge reports 8. Process for adding test forms, signature forms to chart with original data. 9. Communication to Clinician with due dates, notice for outstanding documentation, # of visits for PT, advanced notice of last visit authorized, notice date for new authorization. 10. Editing mode for all documentation until final signature. 11. Access to charts assigned. 13. Report of dates attended and date of SOAP note documentation. 14. Summary of customer satisfaction data. 15. Summary of PT demographics for annual discharges and reason for discharge. 16. Records signatures on forms for audit process.

17 Example of Monthly Chart Audit Patient chart was located in secure location Chart notations and signatures are legible The SOAP notes were signed by the billing clinician The dates of service billed agree with dates of SOAP notes Financial Agreement signed and dated HIPAA form signed and dated Consent forms signed and dated Consent to receive/release information w signature & date Physician referral is current with signature and date Copy of current insurance card Documentation supports ICD-9 billed G-Codes documented 10 visits or 30 days Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N

18 Financial Reports Patient Ledger clearly identifying charges, patient payments, insurance payments and adjustments (including secondary and tertiary insurance), balance Daily encounters with charges Daily receipts by cash, check, credit card Patient payments by date Electronic fund transfer/automated clearinghouse receipts by date List of patients with primary and all secondary/other insurance or guarantor sources (i.e., TEIS, school system) List of Insurance and third-party guarantors with all covered patients

19 Financial Reports Period-to-date, year-to-date CPT codes used; option to run report by provider or for the group Accounts receivable aging reports by patient and third party guarantor Patient credit balances Electronic billing report, including list of all patient charges transmitted Insurance receipts by CPT code Demographic reports with flexibility to extract only needed information (i.e., children under 5) Diagnosis reports Referral information (by physician, appointments, unable to contact)

20 Financial Reports Scheduling reports (availability, patients scheduled) Daily appointments by provider No-shows and cancellations Ability to track and obtain report on patient payments by date Claim denials with explanations Flexible summary reports (i.e., # of unduplicated patients in a time period, # of encounters in a time period, total charges for a time period) List of refunds Report of clinic-initiated adjustments

21 II. Implementation: Interview vendors & make selection Present documents/reports to vendor for feedback Does the system meet your needs? Consider financial terms include startup pricing (hardware, software, maintenance and upgrades, customization of reports, cost to connect, etc.t) Consider how data can be migrated from current system to new system or from paper to electronic system

22 II. Implementation: Interview vendors & make selection IT personnel will need to evaluate privacy and security issues when transitioning to EHR; plan for backup Evaluate training process to be provided & have a contingency plan or back-up plan to address problems throughout the implementation. Process will need approval from university

23 III. Implementation of the EHR: Plan, plan, plan Access readiness-have implementation team and team leaders; if small practice everyone is a team member; have strong and positive advocates for change Conduct Training check computer literacy of staff & train the trainers; insure that each person understands how they will be affected by change and understands the plan

24 IV. Implementation of the EHR: Clarify and prioritize Identify sequential order of clinical tasks/processes: Identify new work tasks & processes to be implemented Identify tasks/processes no longer needed Identify tasks/processes that will continue Create a Pt. chart plan- identify components of a complete chart Understand where you are; where you are going; and, have a plan for getting there Have implementation goals with dates for achieving them

25 V. Implementation of EHR: Achieve meaningful use Improve quality and efficiency of your practice Engage Pts. and their families Improve management of treatment leading to better Pt. outcomes Improve coordination of services Increase preventive care Maximize reimbursement

26 VI. Implementation of EHR: Continue quality improvement Have content and process goals been met? Does workflow need to be re-evaluated? Do staff and faculty roles need to be adjusted? Are you getting data, reports as anticipated? Is technology reliable? Are security measures in place?

27 Cara Boester, M.A., CCC-SLP Director of Clinical Experiences SLP Kelly Pyle, Au.D., CCC-A Director of Clinical Experiences AuD

28 Selection Process So Many Options! Or so we thought Communication Sciences and Disorders

29 Background Needed to bill electronically for Medicaid, Medicare, Private Insurance Researched and contacted vendors who provided more information/presented their product (2009) Point N Click (PnC) MedChart(???) Sycle Communication Sciences and Disorders

30 Did not meet our needs At the time, EMR programs were specifically designed for medical clinics and hospitals. Processes and procedures were very different from a University Clinic that involved student clinicians Communication Sciences and Disorders

31 Unique Needs of a University Clinic 1. Scheduling requirements: Recurring appointments 1 SLP supervising 4 sessions Different rooms Multiple clinicians Overlapping times Individual vs. Group Did I mention reoccurring appointments? 2. 2 practitioners (student/supervisor) 3. Report writing (multiple drafts), feedback to students and signatures Communication Sciences and Disorders

32 Next Step: DIY ISU IT (Academic Tech) department Thought they could build it Server issues Didn t happen Office of Administrative Technologies They decided can t be built and does not exist RFP Request for proposals Get someone who can do it outside of University Communication Sciences and Disorders

33 Request For Proposals (RFP) Needs assessment of essential functions Created Scenarios Audiology Speech language pathology Report Writing Billing Query information (sort by room, clinician schedule, supervisor schedule, disorders, etc ) Communication Sciences and Disorders

34 Response to RFP Submitted nationwide RFP (2011) One Vendor Responded Clearly NO existing program could meet our needs PnC Point N Click: Demonstrated how their existing system COULD be used to perform the procedures outlined in the scenarios. University Negotiated Price Purchased DONE AND DONE! Communication Sciences and Disorders

35 Or so we thought We quickly learned we had purchased PnC s VANILLA product. It COULD do what we needed it to do ONCE we configured it to meet our needs Our IT people knew the product would be vanilla (IT vs SLP/AuD) Communication Sciences and Disorders

36 Configuration Communication Sciences and Disorders

37 Team Administrative Technologies Project Manager Business Analyst Academic Technologies Technical Support Staff Security Officer CSD Clinic Director DCE SLP/AuD Office Manager PnC Support Staff Communication Sciences and Disorders

38 Process Lean Process Mapping Business Analyst Current State, Root Cause, Future State CHANGE our processes/procedures NOT try to fit our clunky ways into the software (required a HUGE mindshift) Why why why why why (5 why s) How long did that take? Every step! Every Process! Streamlined clunky processes 12 month+ process Communication Sciences and Disorders

39 Communication Sciences and Disorders

40 BEFORE Total Current Processes combined = 129 hrs 52.5 min AFTER Total Proposed Processes combined = 40 hrs 10 min Communication Sciences and Disorders

41 Communication Sciences and Disorders

42 Communication Sciences and Disorders

43 Communication Sciences and Disorders

44 Communication Sciences and Disorders

45 Matching Software to the Lean Process Weekly Meeting Full team Go To Meeting with PnC PnC Staff modified software as the processes were described. Process Established Templates Created Everything tested in training version Communication Sciences and Disorders

46 Preparing for implementation Import all existing patients records Entered all student clinician information Entered all supervisor information Create multiple report templates Create workaround for IPA Enter charges associated with billing codes, services and products Communication Sciences and Disorders

47 Go live (2 years later) Training Create Training Document Train Supervisors Train Staff Train Students PnC onsite for one week Roll out in the summer Whole team available How did it go? Communication Sciences and Disorders

48 Smoother than a fresh jar of Skippy Students are technology savvy Training Manual ROCKED Training (well-oiled machine) Team was amazing Communication Sciences and Disorders

49 In Production Communication Sciences and Disorders

50 Administrator maintenance Each semester: Create schedule shells (every supervisor and every student) Enter SLP patient, disorder, reoccurring appt days/times, clinician, and room. Includes group therapy. AuD patients scheduled by office staff Enter specialty time slots in to the clinic schedules Speech Diagnostics Pediatric Clinics Central auditory processing evaluations Offsite placements Train new supervisors and students Communication Sciences and Disorders

51 Daily Use Supervisors and Students view their schedule in PnC All encounters are documented in PnC using reports or notes Directors makes schedule changes as needed Office Staff document noshows/cancellations Communication Sciences and Disorders

52 Slideshow Title (Select: View > Master > Slide Master to edit) Daily Use Check patient in Check patient out Enter Diagnoses Enter Procedures and Units Enter Encounter Code Department Name (Select: View > Master > Slide Master to edit)

53 Has significantly improved efficiency and streamlined processes Created consistency among supervisors (productivity %) Significantly reduces coding errors Allows data to be collected easily about various tasks Cost of goods Number of patients with specific diagnosis Availability of supervisors Types of payee information Can monitor who accesses PHI Communication Sciences and Disorders

54 Quickly view weekly schedule of all supervisors/clinicians/clients Quick view: Dx, Tx ind and group View of room availability Can set alerts for office staff to complete future tasks Allows for instant messaging within the system Waiting list feature Communication Sciences and Disorders

55 Continued quality improvement Run multiple types reports on most any type of information IT person runs bi-monthly security audits Continue to tweak templates for more efficiency in reports. Communication Sciences and Disorders

56 Communication Sciences and Disorders

57 Communication Sciences and Disorders

58 Is it perfect Not all encompassing yet! Store videos & audio NOAH Ease of communication/feedback between supervisor and clinician for lesson plans and diagnostic reports Use of flowsheets No track changes Leaving encounters open Nicknames PnFC, PnCCCCCCCC Communication Sciences and Disorders

59 References J.C. Crosson, C. Stoebel, J.G. Scott, B. Stello & B.F. Crabtree,(2005). Implementing an electronic medical record in a family medicine practice: Communication, decision-making, & conflict. Products Information-Systems-for-Student-Health Communication Sciences and Disorders

60 THANK YOU! Ann Michaels Kelly Pyle Cara Boester Communication Sciences and Disorders

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