Selecting and Implementing EMRs in the FQHC/CHC Setting. TN Primary Care Association JUNE 26, 2009

Transcription

1 Selecting and Implementing EMRs in the FQHC/CHC Setting TN Primary Care Association JUNE 26, 2009

2 2 Presentation Overview Overview of EMR Solutions Financial Incentives for EMR Implementation Selecting a PM/EMR Vendor Implementing PM/EMR Solutions in FQHC/CHCs Q&A

3 3 EMR Overview

4 4 Anatomy of an EMR

5 5 Common Medical Vocabularies What s the Big Deal? ~5,000 hospitals, ~1,000,000 physicians in the United States Healthcare represents about 1/7 th of every dollar of GDP Ours is the only major industry in the United States that has yet to reach a tipping point of automation Why is this? Complexity Medicine is a mix of art and science Still so much to sort out Who gets to choose the standards that must be in place to automate? Think we have standards? Let s talk about the heart attack for a moment

6 6 Ways to Describe a Heart Attack 1. Heart attack 2. Myocardial Infarction 3. MI 4. Coronary 5. Acute Myocardial Infarction 6. AMI 7. Acute Coronary Syndrome 8. Coronary Thrombosis 9. Coronary Occlusion To most people in healthcare this isn t a problem our brains are good at grouping these terms under the one umbrella; computers aren t as smart This is the challenge with semantic interoperability

7 7 Common Medical Vocabularies The Key to Interoperability MEDCIN SNOMED-CT LOINC RXNORM HL7

8 8 Common Medical Vocabularies The Key to Interoperability MEDCIN A proprietary CMV developed by Medicomp Systems and designed as a point of care terminology to support EHRs Contains >250,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy Produces fully structured and numerically codified patient charts that enable the aggregation, analysis, and extensive mining of all clinical and practice management data related to a disease, a patient or a population Preferred CMV by Allscripts and Medical Manager SNOMED-CT The Systemized Nomenclature of Medicine Clinical Terms is a CMV covering most areas of clinical information such as diseases, findings, procedures, microorganisms, pharmaceuticals etc. It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. Helps organize the content of medical records, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research. Preferred CMV by NextGen SNOMED is designed for classification; MEDCIN is designed for point of care use

9 9 Common Medical Vocabularies The Key to Interoperability, (continued) LOINC Logical Observation Identifiers Names and Codes is a universal CMV for identifying medical laboratory observations. Developed by the Regenstrief Institute in 1994 Has expanded to include not just medical and laboratory code names, but also: nursing diagnosis, nursing interventions, outcomes classification, and patient care data set RXNORM - RxNorm is a CMV for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software Produced by the National Library of Medicine In this CMV the name of a clinical drug combines its ingredients, strengths, and form Used by First Databank, Micromedex, MediSpan, Gold Standard Alchemy, and Multum Acetaminophen 500 MG Oral Tablet for a generic drug name Acetaminophen 500 MG Oral Tablet [Tylenol] for a branded drug name

10 10 Common Medical Vocabularies The Key to Interoperability, (continued) HL7 Health Level Seven was founded in 1987 to produce a standard for hospital information systems; ANSI-accredited, it is best known for the interface standards it creates Specifies a number of flexible standards, guidelines, and methodologies by which various healthcare systems can share data. However, the health information enclosed is identified by a multiplicity of code values that may vary according to the entity producing those results; this is a problem for interoperability

11 11 Definitions of Terms Electronic Medical Record (EMR): An electronic record of health-related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within one health care organization. Electronic Health Record (EHR): An electronic record of healthrelated information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization. Personal Health Record (PHR): An electronic record of healthrelated information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual. Source: Defining Key Health Information Technology Terms, National Alliance for Health Information Technology, May 2008

12 12 Ambulatory PM/EMR Conceptual Diagram Electronic Medical Record Chart Repository Interaction Checking MD Documentation Nurse Documentation Decision Support eprescribing Procedure Orders Diagnosis Linking Charge Capture Practice Management Registration Scheduling Eligibility Bed Management Referrals Case Management Chargemaster Claim Creation Clearinghouse Patient/Consumer/Payor Find a Physician Payor/Plan Info Bill Pay Prescription Refill Test Results Web Portal elearning Communication Newsletters CDR CMV CDSS Integration Hospitals and Third Parties PACS Lab Path Blood Bank Pharmacy Bed Management Mat. Management Monitoring Devices Report Generation CDR Clinical Data Repository CMV Common Medical Vocabulary CDSS Clinical Decision Support System

13 13 What s Driving EMR Deployment in the Last Few Years? Patient Safety/Quality of Care The Technology is Finally There Pay for Performance (P4P) Federal Emphasis on HIT Maturity of the Vendor Marketplace Generational Changes in the Medical Community Latest Solution to the Healthcare Crisis Reimbursement Carrots and Sticks New Definition of Standards of Practice to include EMR Recruitment and Retention 2009 Federal Stimulus Program

14 14 EMR Drivers Patient Safety Estimated that 770,000 people are injured each year due to adverse drug events Adverse drug events (ADE) in 5% to 18% of ambulatory patients 190,000 hospitalizations per year result from ADEs Translation of medical research into practice is slow-average of 17 years American adults, on average, receive only 54.9% of the healthcare recommended for their conditions Source: ehealth Initiatives World Health Congress, Jan. 26, 2005.

15 15 EMR Drivers Quality of Care Studies have shown that the leading vendors are improving the quality of care by: Reducing patient wait times in the lobby Alerting clinicians when immunizations are due Increasing quality patient/clinician interaction Patients are spending less time in the office and receiving a greater range of care Standardized education about diseases and treatments Ability to comb vast numbers of records at the push of a button to react to adverse drug interactions, recalls, etc. Vastly improved decision support capability to make better diagnosis decisions Significant reduction in the risk of paper Hurricanes Katrina and Rita

16 16 EMR Adoption Model HIMSS Analytics 2009

17 17 How is Legislation Affecting EMR Adoption? MMA - Medicare Modernization Act Balanced Budget Act Health Information Technology Promotion Act of 2006 Medicare Improvements for Patients and Providers Act of 2008 Provides financial incentives to physicians who adopt electronic prescribing (eprescribing) 2 % payment increase in 2009 and 2010 for regular users 1 % payment decrease in 2011 for non-users, maximum 2% for 2013 and beyond Requires adoption by 2011 Delays any reduction in fees for treating Medicare patients American Recovery and Reinvestment Act of 2009 (ARRA) Provides $19.2 billion for HIT initiatives (HITECH Act) Financial incentives for Medicaid/Medicare providers to use HIT by 2015 Combination of incentive payments, grants and loans for meaningful use of an EHR

18 18 Financial Incentives for EMR Implementation

19 19 ARRA / HITECH Act of 2009 Criteria To be eligible for HITECH incentives providers must be an eligible professional Physician; Physician Assistant; Nurse Practitioner healthcare professionals that are Medicare approved Must use a certified EHR solution. The HITECH Act does not fully define the details of certification or who will provide the certification, however, it does specify that to be qualified as a certified EHR, the solution must: (1) protect the privacy of health information (2) ensure the comprehensive collection of patient demographic and clinical data (3) include patient demographic and clinical health information (4) have the capacity to provide clinical decision and physician order entry

20 20 ARRA/HITECH Act of 2009 Criteria, (continued) Must demonstrate "meaningful use" of the EHR. The ONC will define "meaningful use" by the end of The HITECH Act stipulates that the following conditions for "meaningful use" must be met. The EHR must: Use eprescribing Electronically exchange information Submit clinical quality The Act includes several new security provisions including: Requirement to notify patients and HHS of PHI (Protected Health Information) security breaches New HIPAA regulations regarding business partners (PHRs, HIEs) and enforcement of penalties Restrictions on the sale and marketing of PHI Ensuring that patients have access to their electronic health information Accounting of disclosures of PHI to patients

21 21 HITECH Financial Incentives Medicare incentive up to $44,000 Medicaid incentive up to $65,000

22 22 HITECH Financial Incentives, (continued) Medicaid financial incentives for eligible professionals Eligible professionals include physicians, dentists, certified nurse-midwives, nurse practitioners, and physician assistants who are practicing in Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) led by a physician assistant Eligible professionals must meet minimum Medicaid patient volume percentages 30% or 20% for Peds; and must waive rights to duplicative Medicare EHR incentive payments. Eligible professionals may receive up to 85 percent of the net average allowable costs for certified EHR technology, including support and training up to a maximum level, and incentive payments are available for no more than a 6-year period.

23 23 HITECH Information Disclaimer The HITECH guidelines for participation have not been fully defined; specifically Meaningful Use and individual state guidelines for Medicaid incentives There are various views available as to who, what and how much are covered in the law; seek reliable resources Do your homework and fully discuss incentive opportunities with you legal and/or financial advisors

24 24 Selecting a PM/EMR Vendor

25 25 Selecting a Software Vendor There are a number of ways to go about selecting systems Sadly many approaches are ineffective and result in organizations choosing systems that aren t right for them Two guiding principles should drive vendor selections: Objectivity Buy-in Providers should focus on an OBJECTIVE evaluation of a few categories of requirements Functionality Architecture & Delivery Approach Company Stability Strategic Direction Customer Satisfaction

26 26 Selecting a Software Vendor, (continued) Other key concepts for vendor selections: Organize the selection like a project; it s not simply a to do Get help if you don t have someone in-house who knows the vendor marketplace well Follow your process rather than the vendor s process Get top executives involved early through governance structure Get equal involvement of administrative, operational, financial and clinical folks; try not to forget any key folks Know that there are lots of vendor options out there and many of them aren t good for your organization Try to avoid just going with the vendor the guy down the street went with

27 27 Health IT Software Industry Ratings Standards Certification Commission for Healthcare Information Technology (CCHIT) Voluntary, private-sector organization created to certify HIT products; formed by three HIT industry associations in 2004: AHIMA HIMSS NAHIT The goals of CCHIT certification are to: Reduce the risk of health IT investment Ensure interoperability of health IT products and networks Create incentives and give regulatory relief for health IT adoption Protect the privacy of patients' personal health information

28 28 Health IT Software Industry Ratings Standards, contd. KLAS Independently monitors the performance of HIT software, professional services, and medical equipment vendors on the basis of customer satisfaction and business practices Private company in business since 1997 The overall performance rating is calculated from individual scores for 40 criteria: 28 Performance Indicators (PIs) and 12 Business Indicators (BIs) Evaluations are provided by end users of the product by questionnaires and interviews To be included in the KLAS rankings a vendor/product must have 15 separate evaluations from unique sites HIMSS NACHC

29 29 System Selection Process Overview Cumberland recommends an approach that incorporates all of these components Requirements Gathering Understanding of the operation in question Development of functional and non-functional requirements in key categories and with simple statements Development of deliverables for committee approval Initial to Final List Selection Determination of initial vendor/app. list Use of CCHIT, KLAS, and industry experience data Application of initial requirements to vendor alternatives to assist in down-selecting to final list Development of final vendor list (2 or 3) and facilitation of buy-in with key stakeholders Scored Discovery Day Development of comprehensive packet of materials for vendors to drive their response Identification of vendor of choice (VOC) Contract negotiation support (as requested) Governance Structure Development Joint Cumberland/Client Team Ident. Chartering Project Structure & Management Status Reporting Vendor Communication & Control Scoring Instrument Development Discovery Day Packet Development Coordination of Events Tabulation of Scorecards & Reports

30 30 From Initial List to Vendor Finalists Initial vendor list should be no more than 5-7 and based on: Industry-standard evaluation entities such as CCHIT, KLAS, FQHC Community, etc. Organization s perspective and cost profile Cumberland experience and point of view Requirements discussions This initial list will be down-selected to 2-3 finalists based on: Requirements-based demos Functionality offerings Pricing structure Software platform requirements Vendor/client relationship

31 31 Discovery Day Process A substitute for RFP/RFI processes Often less calendar time-consuming and more effective Based on requirements and scenarios Highly planned/structured Scored Attended by both the selection committee and line people Used to suss out the key differences among vendor finalists Intended to reveal the right vendor of choice Typically followed by contract negotiation and implementation planning We ve created and utilized this technique with many FQHC/CHC organizations to great effect

32 32 EMR Implementation Critical Success Factors

33 33 It s Not About the Software! The objective is improving quality of care and business performance PM/EMR implementation is the catalyst for process redesign Your operations will change dramatically as a result of automating the clinical processes A successful EMR implementation should result in improved quality of care with standardized and codified treatment for your patients Careful planning leads to successful execution The critical success factors (CSF) discussed in the subsequent slides will help position your institution for a successful change initiative

34 34 14 Critical Success Factors 1. Buy-in from the Internal Leadership Team 2. Appropriate Project Governance 3. A Defined Budget with Appropriate Detail 4. Adequate Resource Commitment 5. A Change Management Plan 6. Measurable Milestones and Achievable Targets 7. Thorough Analysis of Current and Future-State Workflows 8. A Sensible Plan for External Interfaces 9. A Sensible Data Migration Plan 10. Sufficient Time for Training 11. Designated Super Users 12. Extra Time for Clinicians During Go-Live 13. A Long-Term Transition Plan 14. A Plan to Succeed Project Management Matters

35 35 Critical Success Factors A Few for Discussion Buy-in from the Internal Leadership Team Senior executives and clinical leadership should be involved throughout the project to demonstrate their own commitment to making the EMR implementation successful Select sponsors or champions who are enthusiastic and well respected by their peers Creating an EMR Steering Committee is a helpful way to include clinical, business, and executive leadership in the design decision process Adequate Resource Commitment Resources should be allocated or committed to the EMR implementation Resources should be given sufficient time for planning, training, and system implementation

36 36 Critical Success Factors A Few for Discussion A Plan to Succeed Project Management Matters The ease of achieving your ultimate goal can vary depending in large part on the planning that goes into the project, particularly with regard to the factors discussed in the previous slides. Selecting a strong project management team to ensure the critical success factors are addressed is imperative to the success of the EMR implementation. The project management team will coordinate and track the many details of an EMR implementation plan and ensure issues are resolved as quickly as possible. They will also help the make certain all the design options are considered and the best decisions are made for the facility.

37 37 Special Considerations for FQHCs & CHCs Not all PM/EMR systems are capable of handling CHC/FQHC unique requirements Special design, configuration and potential workarounds may be required to support CHC/FQHC requirements, including: Demographic Data Capture Information required for reporting purposes May not be standard elements captured by most vendors Financial Sliding Fee Scales Split Billing (UB/HCFA Medicare Part B) Reporting Requirements Many CHCs & FQHCs have significant reporting requirements for grants and other funding agencies

38 38 Questions and Answers

39 39