Systems for Medical Practice in the 21 st Century: EHRs, e

							Systems for Medical Practice in the 21st
Century: EHRs, e-Prescribing and the Medical
Home
Healthcare Information Technology

Saturday, September 6, 2008
Maria E. Rudolph, MPH
                Objectives

• Identify critical success factors for
  successful EHR adoption
• Provide an overview of e-Prescribing
  (eRx)
• Discuss the use of HIT in the new Patient-
  Centered Medical Home (PCMH) model
• Q&A
                Disclosures

• VP, Business Development
  – as of 9/1/2008
• Stock: Cerner, QuadraMed
  – acute care EHR companies
             My Background

• Native of Washington, DC
• Parents in private practice together
• 10 years in acute care setting
  – Implementation of HIS for a community
    hospital in Washington, DC
• 10 years in EHR industry
  – Implementation and Development
• 3 years with medical associations
  – ACC and ACP Informatics
EHR Adoption in Ambulatory Settings

• Nationally, rate of adoption ranges from 15% - 30%
• Higher rates for larger sized practices
   – More resources
• Lower rates for solo and small (5 or fewer) physicians
   – ~5% adoption
• Main barrier = unproven Return on Investment (ROI)
   – Significant investment of time and money
• 75% of patient care is provided in practices with 8 or
  fewer physicians
• 52% of physician practices consist of 3 or fewer
  physicians
  Why EHR Implementations Fail…

• Rarely does the software fail…
• Users fail to adopt
  – No champion
  – No planning
  – No understanding of current processes (“as-
    is”)
  – No design of new EHR-enabled processes
    (“to-be”)
  – Users automate bad processes (“do a bad
    thing faster!”)
                  EHR Project Lifecycle

• DHHS Report* identifies five (5) steps of EHR
  Implementation
   1. Develop Understanding of EMR Functionalities
   2. Conduct Internal Preparation
   3. Identify and Evaluate Potential Vendors
   4. Select Vendor and Negotiate Contract
   5. Implementation and Beyond

   *Assessing the Economics of EMR Adoption and Successful Implementation in Physician Small
       Practice Settings
 1. Develop Understanding of EMR
          Functionalities
• “Caveat Emptor” = Be an Educated Consumer
• Basic functions of an EHR system mimic those of an
  acute care EHR
   –   Write orders,
   –   Document,
   –   Confer/Consult,
   –   Provide Infrastructure: Security, Communicating with other
       systems
• Advanced functions include: clinical decision support,
  population management (quality reporting),
  workflow/task management
• Check out your local hospital’s EHR to get a feel for how
  tasks are accomplished electronically
   2. Conduct Internal Preparation

• Understand what your practice does
  TODAY
• Process analysis approach
  – Review the steps involved for a patient
    encounter, e.g., new visit, recurring visit
  – Involve the staff who actually do the work
  – Account for variations in how tasks are
    accomplished (cross-trained staff)
 3. Identify and Evaluate Potential
              Vendors
• Use the Internet
   – www.cchit.org – Certification Commission for Healthcare
     Information Technology
      • List of vendors that have certified against a baseline (annual) set of
        functional requirements
      • Links to each certified vendor’s website
   – www.acponline.org/ehr - ACP’s EHR Partners Program
      • Pricing Information
      • Product reviews
      • Physician comments/satisfaction levels
• Talk to your colleagues who have implemented
• Investigate local resources:
   – http://mhcc.maryland.gov/electronichealth/cmsdemo/index.html
    4. Select Vendor and Negotiate
               Contract
• Prepare a list of the functions and features you
  want
  – Include any interfacing requirements (information
    exchange with systems outside your practice)
     •   Labs (Quest, LabCorps, local hospital lab)
     •   Imaging Centers
     •   Other facilities (acute care, nursing home, SNF, OP services)
     •   Other physicians
  – This is known in the industry as a Request for
    Information or Request for Proposals (RFI/RFP)
• Send this list out to vendors to complete within a
  specified timeframe.
            Narrowing the Field…

• Review responses from vendors
• Narrow list to 3-4 top contenders
• See the system in action
  – Ask for a demonstration
     • Via Internet
     • On site
  – Ask for a site visit and references
     • Visit the practice site
     • Interview physicians AND staff who use the system about
       ease-of-use, cost, implementation experience, support and
       the extent to which the system has improved how the
       practice operates.
                  Negotiation

• Buying an EHR is like buying a car or a
  house
  – Price is always negotiable
• Make sure there is a clear specification
  (line items) of what you’re purchasing
     1. Software: functionality (typically by module)
     2. Hardware: servers, workstations, monitors,
        printers/scanners, etc.
     3. Services: implementation, training and ongoing
        support
    5. Implementation and Beyond

• Identify a Champion
• Re-engineer processes as needed
• Develop a phased workplan
  – PMS first, then EHR
• TEST, TEST, TEST
• Build in an initial decrease in productivity
  to account for learning
• Determine how much to transition from
  paper charts
          E-Prescribing (eRx)

• What is eRx?
• Benefits and Challenges of eRx?
• How?
                  What is eRx?

• Electronic transmission of a medication
  order
  – NOT faxing through a fax server
  – Transactions are based on NCPDP SCRIPT
     • Covers eRx, e-Refills, Rx History, Eligibility and
       Formulary
     • Not all EHRs support all transactions
• “Stand-alone” vs. “EHR-embedded” eRx
                SureScripts

• SureScripts runs the e-Rx network
  – Created by retail pharmacy association
  – Pharmacy Health Information Exchange
  – Recently merged with Rx-Hub (PBMs)
• Applications/EHRs are certified by
  SureScripts
  – “Gold” certification: supports all NCPDP
    transactions
  – “Standard” certification: where most vendors
    are today in eRx support
                 Benefits of eRx
• Benefits
  – Safety: legibility
     • CMS incentives/penalties for eRx (tied to SGR
       legislation)
  – Timesaver for practice
     • Reduction in calls from patients and pharmacists
     • Patient convenience
             Challenges of eRx

• Challenges
  – Controlled substances not allowed
    • DEA proposed rule is extremely onerous to docs
       – In-person registration/validation
       – 2-factor authentication, e.g., token
  – Inconsistent adoption by pharmacies
    • Local and national
    • Pharmacies have not adjusted workflow to manage
      SureScripts transmissions
    How to Get Started with eRx?

• Become educated
  – Surescripts website:
    http://www.surescripts.com/get-
    connected.aspx?ptype=physician
• Decide if you want to use a stand-alone
  eRx or an EHR with eRx embedded
  – Workflow considerations
  – Cost implications
  – Information capture and maintenance issues
    HIT and the Patient-Centered
           Medical Home

• Model of primary care promoted by AAP,
  ACP, AAFP and AOA
  – First contact
  – Continuous
  – Comprehensive
  – Physician-directed and coordinated
    • Team-based approach
  – Emphasizes patient-centeredness/activation
    • Based on relationship with a personal physician
  Technology in the Medical Home

• Technology facilitates higher levels of
  medical home capability:
  – Level 1: PMS, registry, no EHR
  – Level 2: PMS and EHR
  – Level 3: PMS and advanced EHR
     • eRx, population management reporting
• CMS Demonstration to evaluate PCMH
  – MD not eligible because of CMS EHR Demo
• Other demos by commercial payors, QIO’s
            PMS functionalities

• Scheduling
  – Open access, expanded hours, patient
    selection of personal physician
  – Patient portal for self-scheduling,
    communication (email) with practice and/or
    physician
• Collection of demographics and billing
  information
  – For reporting, identifying populations
           EHR functionalities
• Clinical data collection
  – Structured documentation of encounter
  – Plan of care
• Educational materials for patients
  – Self-management
       Advanced EHR functions
• eRx
• Clinical decision support
  – Reminders, e.g., health maintenance
  – Chronic care guidelines, e.g., CHF, DM2
• Clinical reporting
  – Benchmark within practice
  – National benchmark
• Test tracking – labs
• Referral tracking
            PCMH Resources

• NCQA website
  – http://www.ncqa.org/tabid/631/Default.aspx
• The Patient-Centered Primary Care
  Collaborative
  – www.pcpcc.net
       Q&A



 Contact Information:
Maria E. Rudolph, MPH
mrudolph@e-mds.com

     Thank You!