MSCG Consultant Quality Series: Using Health Information Technology to Improve Quality in Health Centers Thursday, November 6, 2012 Jane Segebrecht U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care 1 Webinar Overview Health Center Quality Strategy Why Health Information Technology (HIT)? Current State of EHR Adoption in Health Centers Health Information Technology Deep Dive Health Center Program and HIT Meaningful Use of Electronic Health Records (EHR) Implementation Approaches & Consideration HIT Issues HCCN Models Consultant Resources Assessment 2 Health Center Quality Strategy Better Care ⃘ Healthy People & Communities ⃘ Affordable Care Strategy Implementation INTEGRATED HEALTH SYSTEM 1. Programs/Policies 2. Funding Priorities & Goals 1. Implementation of QA/QI Systems All Health Centers fully implement their QA/QI plans 2. Adoption and Meaningful Use of EHRs All Health Centers implement EHRs across all sites & providers 3. COMPREHENSIVE SERVICES Patient Centered Medical Home Recognition All Health Centers receive PCMH recognition 4. Improving Clinical Outcomes All Health Centers meet/exceed HP2020 goals on at least one UDS clinical measure ACCESS 5. Workforce/Team-Based Care All Health Centers are employers/providers of choice and support team-based care INTEGRATED SERVICES 3. Technical Assistance 4. Data/Information 5. Partnerships/Collaboration 3 Shared Accountability for Quality in Health Centers 4 Why Health Information Technology in Health Centers? Enables reporting and benchmarking to elucidate quality of care provided in health centers and provides opportunity for continuous quality improvement. Enhances health center role in broader connected healthcare landscape and supports exchange of information between providers/care settings and patients/care settings. Positions health centers at an advantage for the evolving health care landscape. Supports practice transformation efforts including providing a strong foundation for Patient Centered Medical Home. 5 2011 UDS EHR Data EHR Adoption By Division, 2011 UDS 2015 Goal: 100% of Health Centers use EHR at All Sites 100% 90% 80% 70% 60% 2012 Goal: 50% of Health Centers use EHR at All Sites 50% 40% 30% 20% All Sites 10% Some Sites 0% National CSD NCD NED SWD 6 Percentage of Health Center EHR Adoption by State 7 Patient Centered Medical Home Recognition 8 Selected HIT Investments to Date • Health Resources and Services Administration: – Health Center Controlled Networks o Approximately $120 million to over 60 HCCNs since 2007 – Health IT Recovery Act Funds for implementation and innovation grants o $27.8 million in September 2009 and $84 million in June 2010 – Capitol Improvement Program o Recovery Act funding for infrastructure improvements and included Health IT projects for the enhancement or the purchase of new EHR system – Beacon Communities o $8.5 million to fund 85 health centers in 15 Beacon Communities in 2011 to enable center participation in community-wide healthcare improvement initiatives 9 Selected HIT Investments to Date • Centers for Medicare & Medicaid Services – Medicare and Medicaid EHR Incentive Program • Office of the National Coordinator for Health Information Technology – Selected sample of HITECH Act funding: State HIE, Regional Extension Centers, Job Training, Beacon Communities 10 Health Center Controlled Networks (HCCN) FY13 Funding Overview Purpose: To support the adoption, implementation, and meaningful use of Health Information Technology (HIT) and technology-enabled quality improvement strategies in Section 330 funded health centers. Project period start date: December 2012 Project period: up to 3 years 11 11 HCCN Program Requirements 1. Adoption and Implementation Activities to assist participating health centers to effectively adopt and implement an ONC-certified EHR system at all sites. 2. Meaningful Use Activities to assist participating health centers to become meaningful users of EHR systems and have their providers receive EHR incentive payments. 3. Quality Improvement Activities to assist participating health centers to improve operational quality, reduce health disparities, and improve population health through HIT, including becoming recognized as a Patient-Centered Medical Home. 12 MSCG Consultant Quality Series: Health Centers and the Use of Health Information Technology Thursday, November 6, 2012 Diane Gaddis, FHIMSS, CPHIMS, CPHIE, CEO/President Community Health Centers Alliance 13 Outline • Meaningful Use and Regional Extension Centers • Types of Health IT Tools • Health Center Program Requirements – How can Health IT assist/Impact – Meaningful Use Tie In – Other considerations/questions for Health Centers • Overview of Implementation Approaches & Consideration • HIT Issues – Deciphering Fact vs Perception • HCCN Models 14 Meaningful Use & Regional Extension Centers Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health system 15 Meaningful Use & Regional Extension Centers 16 Meaningful Use & Regional Extension Centers Medicare EHR Incentive Program Medicaid EHR Incentive Program Year 1 options Must be a meaningful user in Year 1 Adopt/Implement/Upgrade option in Year 1 Who is eligible? 5 types of EPs, subsection (d) hospitals and CAHs 5 types of EPs, acute care hospitals (including CAHs) and children’s hospitals Important dates Last year to start is 2014 Last payment is in 2016 Last year to start is 2016 Last payment is in 2021 Fee schedule reductions Begin in 2015 for EPs that are not meaningful users None Meaningful use definition MU definition will be common for Medicare States can adopt a more rigorous definition (based on common one) Who will implement? Federal government (will be an option nationally) Voluntary for states to implement Use of EHRs, visit: EHR Incentive Program For more information on Meaningful Sources: Medicare and Medicaid http://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp#TopOfPage 17 Meaningful Use & Regional Extension Centers Medicare EHR Incentive Payments • Maximum incentives are $44,000 over 5 consecutive years • Incentive payments decrease if starting after 2012 • Incentive payments based on Fee-forService allowable charges • Must begin by 2014 to receive incentive payments; last payment year is 2016 • Extra amount available for EPs practicing in predominantly Health Professional Shortage Areas Medicaid EHR Incentive Payments • Maximum incentives are $63,750 over 6 years (do not need to be consecutive) • The first year payment is $21,250; $8,500 for next 5 years • Must begin by 2016 to receive incentive payments; last payment year is 2021 18 Meaningful Use & Regional Extension Centers HITECH Act • $677 million in funding established 62 RECs nationwide to: – Provide training and support services to assist doctors and other providers in adopting EHRs – Support and serve health care providers to help them quickly become adept and meaningful users of EHRs – Offer information and guidance to help with EHR selection, implementation, project management, and attainment of MU 19 Types of Health IT Tools • Practice Management Systems • Electronic Health Records • Electronic Oral Health/Dental Records • Population Management Registries • Data Warehouses • Reporting Tools • Patient Portals • Health Information Exchanges • Tele-health technologies 20 Practice Management Systems(PMS) • Appointments/registration • Enhanced CHC specific demographic data • Charge capture/time of visit collections • Fee schedules and contract adjustments • Insurance and patient billing/collections • Non-clinical outcome based UDS reporting • Revenue/adjustments/collections reporting 21 Electronic Health Records (EHRs) • Nursing and provider care documentation • Protocols, flags, care alerts • Templates to prompt documentation • Labs and images • Clinical outcome reporting • ePrescribing, drug-allergy interactions • Orders • Scanned documentation 22 Electronic Oral Health/Dental Records (EOHR/EDR) • Technical, hygienist, dentist documentation • Treatment plans • Xrays/images • Notes 23 Population Management Registries • Disease/Condition specific listings • Criteria based alerts or reminders • Summaries/dashboards for key indicators • Patient reminder letters 24 Data Warehouses • Confused with Data Marts • Combines data from multiple systems • Standardizes terms from disparate systems • Allows more complex reporting/analysis • Advanced views into data • Health Center comparatives 25 Reporting Tools • Ad hoc/quick inquiries within products • Crystal reporting • SQL (structured query language)reports • Separate systems vs production systems 26 Patient Portals • Patients, parents, family care teams • Request appointments • Access to lab results/ Visit summaries • Medication refill requests • Messages to provider care teams • Password protected • Not yet common; driven by Meaningful Use 27 Health Information Exchanges (HIE) • Maturity varies by state and market • Centralized vs federated models • Provider-to- provider secure messaging • Composite chart views or • Record locator/patient lookups • Patient access to HIEs vary 28 Tele-health Technologies • Video conferencing for consultation • Upload of patient device monitoring data • Specialized examination equipment 29 1-Needs Assessment Health IT Possibilities/Impact • Uniform Data Systems reports by zip • Zip code by location • # of referrals outbound by specialty • # of patients by chronic condition • # of patients by preferred language 30 1-Needs Assessment Meaningful Use Tie In MU Core 3: Maintain up-to-date problem list/diagnoses MU Core 7: Capture demographics, including preferred language, ethnicity, race MU Menu 3: Generate lists by specific condition Other Considerations/Questions • Health Centers should run UDS reports more than once a year. Valuable analysis tool • Does the health center know the quantity of referrals by service type in generates? • What is the health center’s reach for each of its locations? 31 2-Required & addt’l Services Health IT Possibilities/Impact • Data capture for enabling services offered and provided • Capturing all procedures/services – including non-billable • Referrals to internal & external services tracked through to completion • Preloaded list of vetted community resources/partners • Generation of care related patient reminders (ie flu) 32 2-Required & addt’l Services Health IT Possibilities/Impact • Automated appointment reminders via ancillary call systems • Flags or care alerts for required screenings • Customized care documentation templates to prompt thoroughness • Patient education libraries – English, Spanish most common • Custom upload of patient education in different languages 33 2-Required & addt’l Services Health IT Possibilities/Impact • Patient assessment templates- learning, home environment • Behavior health assessment – PHQ9 • Hospitalization tracking and follow through (ie Estimated Delivery Dates) • Patient call documentation • Tele-health for rural / remote access 34 2-Required & addt’l Services Meaningful Use Tie In MU Core 9: Record smoking status MU Menu 4: Send preventive/follow up care reminders to patients MU Menu 6: Patient education resources provided MU Menu 7: Medication reconciliation for transitions from another setting MU Menu 8: Transition of care record to another setting MU Menu 9: Immunization registry interface/uploads 35 2-Required & addt’l Services Other Considerations/Questions • Ease of use in customization may compromise reporting, vendor support, standardization •‘Click only’ templates raise concern • How does the health center capture services provided that are not billable? • How are providers or care teams prompted to provide required services? • How are systems used to identify populations requiring reminders or follow up? 36 3-Staffing Requirement Health IT Possibilities/Impact • Selection of preferred primary provider • Visits by age or condition can predict staffing needs • Patient volume to staffing ratios • Timeliness of appointment availability tracking • Audit trails allow monitoring of staff access/timeliness 37 3-Staffing Requirement Health IT Possibilities/Impact • Staffing Analytics • Role based access to systems • Referrals – appointment wait times • Patient call/response tracking for timeliness/delays • Role based workflows/task lists 38 3-Staffing Requirement Health IT Possibilities/Impact • Use of tele-health to expand provider or consultation reach • Centralized medical record functions • Coordinated and streamlined referral authorization requests • ePrescribing/ electronic refill requests • Patient flow tracking 39 3-Staffing Requirement Other Considerations/ Questions • Again, UDS reports are valuable • Absence of regular analysis and trending is cause for concern • Must ensure enough software licensing for appropriate access based on required users • What data is evaluated monthly to gauge productivity or expected efficiencies? • How far out is next available appointment for new patients? • Under open access, how many patients deferred? Is there tracking mechanism for this? 40 4-Accessible Hours/Locations Health IT Possibilities/Impact • Identify populations best served by non-standard hours • Patient portals/secure messaging allow after-hours communication • EHR access via partnered locations (ie hospitals, mental health facilities) • Scheduling templates for open access • No show tracking • Centralized scheduling/flexible scheduling views • Tele-health for expansion into limited reach areas 41 4-Accessible Hours/Locations Other Considerations/Questions • Is there tracking to understand difficulties in transportation for locations? • Is zip code analysis performed? • What no-show analysis is performed to understand reasons for high rates? • What is assessed to determine that hours of operations best meet the needs of the local population? 42 5-After Hours Coverage Health IT Possibilities/Impact • Secure access to electronic records after hours • ePrescribing with medication history • Portals/messaging to reduce unnecessary calls • Access to clinical information from hospital 43 5-After Hours Coverage Meaningful Use Tie In MU Core 4: ePrescribing MU Core 5: Up-to-date medication list MU Core 6: Maintain active allergy list MU Core 15: Security risk analysis 44 5-After Hours Coverage Other Considerations • Are providers / triage team given remote access? • When are the after-hours notes entered into medical records? • How is this tracked? 45 6-Hospital Admitting/Continuum Of Care Health IT Possibilities/Impact • Tracking for referrals to hospitals • Import of discharge summaries • Reports based on expectant mother Estimated Delivery Date • Clinical visit summary reports • Continuity of Care Document exports Meaningful Use Tie In MU Core 14: Secure health information exchange 46 7-Sliding Fee (SF) Discounts Health IT Possibilities/Impact • Capture of required data for SF eligibility • Scanning of supporting documentation • Fee schedules by specialty (SF may differ for medical vs dental) • Adjustments captured by different SF categories for analysis • Automatic calculations by system 47 7-Sliding Fee (SF) Discounts Other Considerations • Flag - Calculators or cheat sheets used for SF discounts • Where is supporting documentation stored? 48 8-Quality Improvement/Assurance Plan Health IT Possibilities/Impact • Clinical decision support tools (ie drug interaction checking) • Visual indicators for out of range results • Protocol / guideline based compliance reminders • Patient specific care alerts or flags • Electronic peer chart review 49 8-Quality Improvement/Assurance Plan Health IT Possibilities/Impact • Audit logs on care team entries • Referral tracking and follow up • Lab utilization vs necessity • Custom medication lists by specialty/provider • Standing order authorizations and issuance 50 8-Quality Improvement/Assurance Plan Health IT Possibilities/Impact • Audit logs on care team entries • Referral tracking and follow up • Lab utilization vs necessity • Custom medication lists by specialty/provider • Standing order authorizations and issuance 51 8-Quality Improvement/Assurance Plan Health IT Possibilities/Impact • Outcome reports by chronic disease states • Reporting for co-morbidity indicators • UDS clinical outcome reports • Patient engagement (ie flowsheet trending, clinical summary handouts) 52 8-Quality Improvement/Assurance Plan Meaningful Use Tie In MU Core 1: Computerized provider order entry MU Core 3: Maintain up-to-date problem list MU Core 8: Record vital signs/display charts including BMI MU Core 9: Record smoking status MU Core 10: Report quality measures MU Core 11: Clinical decision support rules MU Core 13: Clinical summary handouts 53 8-Quality Improvement/Assurance Plan Meaningful Use Tie In MU Menu 2: Lab results as structured data MU Menu 3: Generate lists based on specific conditions MU Menu 4: Send preventive/follow up care reminders MU Menu 5: Patient access to lab results, problem list, etc MU Menu 7: Medication reconciliation 54 8-Quality Improvement/Assurance Plan Other Considerations/Questions • Canned system reports do not typically meet health center needs • Advanced report development skills/knowledge often required • Testing/validating report data is necessary • Organization should have a methodical approach to using data for assessment and improvement efforts • Request to see reports generated against health center’s QI program elements. • What flags/indicators are used in the EHR to prompt provider or serve as visual aid? • Is health center able to demonstrate how electronic charts are reviewed by peers? • What reports are available daily to monitor against expected quality efforts? 55 9-Key Management Staff Health IT Possibilities/Impact • Key performance indicator reports to management • Pre-designed reports available for on-demand access 56 10-Contractual/Affiliation Agreements Health IT Possibilities/Impact • Data access agreements Meaningful Use Tie In MU Core 15: Security risk assessment 57 11-Collaborative Relationships Health IT Possibilities/Impact • • • • Participation with HIE efforts Accountable Care Organization analytics Beacon Community participation Partnerships with Universities for population based studies Meaningful Use Tie In MU Core 15: Health information exchange MU Menu 9: Immunization registry upload MU Menu 10: Syndromic surveillance data upload 58 12/14-Financial Management/Budget Health IT Possibilities/Impact • E&M coding assistance • Analysis of service utilization by condition • ePrescribing to internal vs external pharmacies • Managed care utilization vs capitation reporting • Lab utilization reports • Drug formulary checking (benefits ACO, profit sharing managed care) 59 12/14-Financial Management/Budget Meaningful Use Tie In MU Core 3: Up-to-date diagnosis MU Core 4: ePrescribing MU Menu 1: Drug formulary checks 60 13-Billing And Collections Health IT Possibilities/Impact • Interfacing/integration between PMS and EHR • Integrated Insurance/Medicaid eligibility-appt schedules • Medicaid batch eligibility prior to bad-debt write off • Centralized and standardized collection practices • Systems for tracking individualized payment plans • Flexible adjustment codes for deeper analysis 61 12/13/14-Financial Mgmt/ Billing and Collections Other Considerations/Questions • Are reports run for use in managed care plan analysis? • Does health organization use aging reports by D.O.S. vs date billed to assess billing operations? • What reports are run to assess extent of contractual adjustments against actual valid contracts? 62 15 -Program Data Reporting Systems Health IT Possibilities/Impact • PMS/EHR systems to produce UDS, Ryan White, or other reports Other Considerations • Garbage in; garbage out. • Reporting issues often tied to usage or configuration • If a health center states that systems cannot generate required reports, drill down into efforts to resolve. 63 16-19 Project Scope/Governance Health IT Possibilities/Impact • Reports to monitor patient population and services • Reports to monitor patient population/services • Reports on “user” criteria • Summary reports on population and need 64 Implementation Approaches For new EHRs….Baby Step vs Big Bang Baby Step Pros: • Productivity levels (revenue) return to normal more quickly • Reduced culture shock • Ease into workflow modifications • Quicker rollout of modular functionality Baby Step Cons: • Full benefits of EHRs realized more slowly • Computer savvy proponents need patience 65 Implementation Approaches For new EHRs….Baby Step vs Big Bang Big Bang Pros Big Bang Cons • Comprehensive • Greater amount of time deployment/ more functionality • More time spent on testing, training, workflow assessments required for build and configuration • Significant negative productivity impact potential • Larger upfront investment for resources • Elongated ROI timeline 66 Implementation Approaches Rip and Replace…. Ripping out one PMS/EHR system and implementing another Most EHRs do NOT have an easy or inexpensive data migration export feature. • Systems are multifaceted with complex data relationships • Migration to new system takes extensive planning and coordination • Erroneous mappings or unmapped data from migration affects patient care/safety • Vendor costs to pull data out of old system in meaningful /industry standard formats • There are costs from new vendor to import if possible • Many vendors do NOT import historical PMS data; must keep old system 67 HIT Issues –Fact vs Perception • Core competency of health centers: Patient care and meeting community Needs; – NOT Health Information Technology • One or two IT people within a health center cannot be experts at all areas required in HIT management • Decision should be driven by clinical and business needs NOT an IT person 68 HIT Issues –Fact vs Perception Rip & Replace – why? • Blaming EHR system for care or documentation deficiencies – Why? Why? Why? Why? Why? • Note – There is NO perfect system! • Can the practice document several concrete examples of major problems to warrant a move? • Can the practice document steps to resolve issues? • Is there documentation of dialogue with vendor/support entity? • Does a health center have influence with vendor/support entity? 69 HIT Issues –Fact vs Perception • Budget/cost issues? • 5 year Total Cost of Ownership (TCO) analysis highly recommended • Double vendor recommendation for hardware costs under selfhosted/managed models • Must factor in internal staff/consultant costs if comparing in-house vs outsource models • Intangible costs – staff stress, morale • Extensive staff time for migration efforts, including QA • Low cost acquisition may mean high recurring fees • Low cost acquisition may mean extensive billable (unexpected) resource hours 70 HIT Issues –Fact vs Perception The consultant’s role is to …. • Ask probing questions to clearly understand issues and steps taken to resolve • Advise on quality due diligence process for product selection or migration considerations • Caution against a switch when a reconciliation/ renegotiation might best serve health center and patients • Provide unbiased resource material or recommend additional technical assistance 71 HIT Issues –Fact vs Perception The consultant’s role is …. • NOT to make recommendation on what product to choose • NOT to recommend one solution partner over another • NOT to assume that health center perceptions on issues are reality 72 HCCN Models Yesteryear • Geographically centered • Collaboration and centralized solutions across several area – not just HIT • Peer-to-peer health center rapport central to success and governance • Smaller number of members to support tighter collaboration 73 HCCN Models Today • Geography no longer a factor • Health IT hosting/management seen as sustainable–vendor ASP similarities • HIT product centric • Less consensus building; more one-on-one customized consulting • Large volume of CHC customers required for self-sustainability 74 HCCN Strengths • Health center focus and understanding • Manage many HIT administrative duties • Leveraged vendor negotiation to benefit health centers • Central knowledge base/solutions spread across several health centers • Possibly more influence on functionality roll out timelines • More customized hand-holding 75 HCCN Considerations • Sustainability risk without large customer base or other revenue contributing business lines • Health center governance may hinder business evolution due to limited expertise • Collaboration takes patience and deference for others’ contributions • Bundled offerings not always valued appropriately by health centers • Depth of Key Staff 76 BPHC Consultant Resources: Health Centers Replacing or Adopting a New EHR System • HRSA’s Office of Health Information Technology and Quality EHR guideline guide • HIT Health IT Adoption Tool Boxes • The Office of the National Coordinator for Health Information Technology • HIT Regional Extension Center program • The AHRQ National Resource Center for HIT 77 77 BPHC Consultant Resources: Health Centers Navigating Meaningful Use • Medicare and Medicaid EHR Incentive Programs • HRSA’s Office of Health Information Technology and Quality Meaningful Use Resource Page • Certified HIT Product List 78 78 BPHC Consultant Resources: Health Centers Navigating the Use of HIT for Quality Improvement (1/2) National Association of Community Health Centers HRSA’s Office of Health Information Technology and Quality webinar series HRSA Office of Health Information Technology and Quality main page FTCA Resources BPHC QI Plan Learning Series and Modules BPHC Training and Technical Assistance HIV/AIDS Bureau Quality Resources 79 79 Additional Resources • Health Center Beacon Awards http://www.hrsa.gov/about/news/2011tables/beaconawards.html • Find a HCCN http://findanetwork.hrsa.gov/Search_OHIT.aspx • Regional Extension Center Program http://healthit.hhs.gov/portal/server.pt/community/hit_extension_p rogram/1495/home/17174 • HRSA Network Guide http://www.hrsa.gov/healthit/networkguide/ 80 BPHC Consultant HIT Resources: Health Centers Navigating Patient Centered Medical Home (2/2) • PCMH Readiness Assessment Tools – Primary Care Development Corporation (PCDC): http://www.pcdc.org – PCMH Assessment (PCMH-A) from the Safety Net Medical Home Initiative: http://www.safetynetmedicalhome.org/practicetransformation/assessment – Medical Home Implementation Quotient Assessment (MHIQ) from TransforMED: http://www.transformed.com • PCMH Change Concepts: http://www.safetynetmedicalhome.org/change-concepts • Patient-Centered Primary Care Collaborative (PCPCC): http://www.pcpcc.net/content/pcmh-outcome-evidence-quality 81 BPHC Consultant HIT Resources: Health Centers Navigating Patient Centered Medical Home • Agency for Healthcare Research and Quality (AHRQ) PCMH Resource Center: http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483 ⁻ Clinical Practice Guidelines: http://www.ahrq.gov/clinic/cpgsix.htm ⁻ US Preventive Services Task Force: http://www.uspreventiveservicestaskforce.org/tools.htm ⁻ Consumer Assessment of Healthcare Providers and Systems (CAHPS patient experience survey): https://www.cahps.ahrq.gov/default.asp ⁻ Innovations Exchange: http://www.innovations.ahrq.gov/ ⁻ Patient Health Literacy Toolkit: http://www.ahrq.gov/qual/literacy/ 82 Contact Information Bureau of Primary Health Care Office of Quality and Data Health Information Technology Branch For any health center HIT related technical assistance or inquires: BPHC_HIT@hrsa.gov 83 Questions & Answers 84 84