selecting and implementing a meaningful ehr system

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


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


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


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


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”


• 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


• 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


“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


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


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


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.


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.


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.


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


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


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


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


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


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


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


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.



• 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


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


http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf


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

http://www.ncqa.org/

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?


This presentation will be posted at: TriStateREC.org

END


Objective Scoring Tool


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


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


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”


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


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


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


# 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


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


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


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

selecting and implementing a meaningful ehr system

Documents

national coordinator

human services

ehr office flowevaluate

scott1rec support

practice consulting

practice transformation

best fit

vendors functionality