AHCCCS - 2007 Medicaid Transformation Grant Final Report

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5.0 Phase 3 – Web Based EHR

5.1 Project Initiation
The desire to collaboratively foster EHR adoption in Arizona is not new. As early as ten years ago, small groups of forward-thinking providers, employers and health plans had piloted various EMR adoption efforts, in the "pay for use" precursor to "pay for performance." Most recently, the Arizona Health e Connection board of directors obtained a favorable legal opinion regarding their collective ability to create a joint incentive pool for this purpose. So it is upon this rich foundation of collaboration and innovation that the EHR collaborative was born. The vision and support of AHCCCS Director Anthony Rodgers gave substance last year to the Arizona EHR Collaborative Purchasing Program (CPP). This enterprise evolved into the Purchasing and Assistance Collaborative for Electronic Health Records (PACeHR) funded by the Medicaid Transformation Grant and in-kind funding. Monies were used to create the project plan; design the proposal request for proposal (Standardized Inquiry) for PACeHR's web-based EHR, including evaluation tools and processes; orchestrate EHR procurement and vendor selection from 16 proposals using an innovative process with external oversight from Gartner that included 19 volunteer providers and subject matter experts (IT, law, and business) and provided opportunity for community participation in the demonstration and selection process.

5.2 Requirements Definition
The requirement of the EHR project was to develop a collaborative that would provide products and services to small and medium-sized primary care healthcare providers as a means to accelerate the adoption of EHRs.

5.2.1 Environmental Scan and Needs Analysis
In order to determine the needs of practitioners who would utilize the service and the current landscape of EHR use in Arizona, PACeHR utilized data from two Arizona surveys and information from Health-e Connection (AzHeC) detailed below.

First, AHCCCS sponsored a study conducted by The Center for Health Information & Research (CHIR) in which CHIR collected responses submitted by Arizona providers from a survey that was distributed as part of their license renewal process (Appendix A). The study was conducted over a two-year period between 2007 and July 2009 in order to allow for a complete renewal cycle. Interim reports were prepared with the final report expected in 2010. The purpose of the study was to capture the use of EMRs by Arizona providers as well as physicians’ attitudes toward a HIE. Findings listed in the most recent report include:

Use of EMRs/EHRs

Barriers to Implementing EMRs/EHRs

The second survey administered was specifically designed to address EHR use and perceived needs of an organization to facilitate EHR adoption (Appendix B). It was created and then disseminated through local provider organizations during the last quarter of 2008. Over 1,100 Arizona clinicians from more than 300 practices responded by completing (on line or fax) the EHR Collaborative Purchasing Program Letter of Interest (LOI). The majority of respondents (72%) did not have an EHR. EHR owners, however, expressed interest based on a less than satisfactory EMR experience, and/or desired access to the other features of PACeHR.

AZ Comparison - Providers with and without EHRs

In addition, the EHR Collaborative Purchasing Program Letter of Interest garnered valuable data; its responses also indicated:

Arizona´s small to medium size practices were interested in collaborative EHR system purchasing

The third contributor to PACeHR´s needs assessment originates from AzHeC. AzHeC is a not-for-profit organization whose mission is to lead Arizona´s establishment of health information exchange (HIE), and adoption of health information technology (HIT). AzHeC created a five-year "Roadmap" to establish Arizona´s health information infrastructure. The "Roadmap" for health information infrastructure also emphasized the need for EHR adoption in order to have integrated statewide health information systems and data exchange because EHR use is the foundation of effective health information exchange.

The survey results and Health-e Connection report assisted in identifying provider requirements for EHR and determining the strategy for supporting EHR adoption.

5.3 Development
The project team and consultants determined that as the initial focus, a web-based strategy was the most flexible EHR solution to meet the needs of providers across Arizona because few hardware and software resources would be required compared to an in office server based solution. PACeHR was formed to provide EHR services and implementation assistance to small and medium sized practices. The organization facilitated due diligence required to select technology & service providers through a research and analysis process that is typically unachievable by this size practice.

5.3.1 PACeHR Formation
Although PACeHR´s roots originate from AHCCCS (Arizona´s sole Medicaid Agency), the Project Team and Director of AHCCCS recognized that PACeHR´s success – and the success of EHR use – depended upon a larger audience than just AHCCCS providers. Provider feedback stressed their need for one system that could accommodate both AHCCCS and non-AHCCCS patients. Physicians and providers did not want to use one system for AHCCCS patients and a different system for all other patients. This was the key reason that PACeHR separated from AHCCCS. PACeHR incorporated as a 501c3 (non-profit) corporation on June 12, 2009.

PACeHR´s organizational structure was founded for the purpose of governance and business operations and is displayed in Figure 1. The Team established a mission and vision for PACeHR that every Arizona clinician will have access to an affordable, interoperable, web-based electronic health record solution that includes support and related services. PACeHR planned to leverage web-based technologies, economies of scale, aligned metrics, and strategic partnering to improve quality, safety and efficiency while promoting a community of information sharing through the use of health information technology & electronic access to data.

Figure 1 PACeHR Organizational Structure
PACeHR Organizational Structure

5.3.2 Vendor Selection Process
PACeHR also needed to construct a process to select EHR vendors. First steps included assembling an evaluation panel to assist with EHR vendor review and selection. Their roles and responsibilities included participating in the Offeror´s detailed reviews of SI responses and providing feedback for EHR finalist demonstrations. Members of the Evaluation Panel are listed in Table 2

Table 2 PACeHR Vendor Evaluation Panel

Arizona Medical Association. AZ Osteopathic Medical Assn.
American Academy of Peds.- AZ Chapter AZ Health Care Assn.
American Coll. of Obstet. & Gyn.- AZ Chapter AZ Health-e Connection
American Coll. of Physicians-AZ Chapter Health Services Advisory Group
Medical Group Mgmt. Assn.- AZ Chapter Maricopa County Medical Society
AZ Healthcare Info. Mgmt. Systems Society AZ Nurse Practitioners Council
AZ State Assn. of Physician Assistants AZ Dental Assn.
AZ Latin-American Medical Assn. Pima County Medical Society
AZ Partnership for Implementing Pt. Safety AZ Hospital & Healthcare Assn.
AHCCCS health plans & contractors

To enable an appropriate due diligence process, tools listed below were created to identify the EHR functionalities and services that PACeHR would support. Requirements for a web-based EHR system were communicated through a Standardized Inquiry (SI) / Request for Proposal process for interested vendors. The process of developing the SI was lengthy, and required substantial legal input due to contract requirements of AHCCCS. Interested EHR companies were to provide a written response in the designated format and present (if selected as a finalist) demonstrations of the products(s) being offered that best fulfilled the requirements of the SI. The full SI is attached. Main components included:

Processes and tools to evaluate, vet, and select EHR software vendors and Information Technology partners were applied by the Panel to the vendor selection and included:

Gartner, a nationally-known expert in healthcare and information technology consulting, provided project oversight throughout the evaluation process. Gartner was actively involved in the due diligence applied to the processes. Upon completion of their work with PACeHR, Gartner issued a white paper inspired by the experience.

The complete evaluation process is illustrated in the attached diagram.

The process of developing PACeHR and vendor selection was complex and the time from developing the organizational structure to selection of vendors took well over one year. The timeline for SI development and vendor selection is illustrated in Figure 2

Figure 2 PACeHR Timeline for Electronic Health Record Vendor Selection

PACeHR Timeline for Electronic Health Record Vendor Selection

5.4 Implementation of PACeHR
The PACeHR implementation strategy was to roll out the PACeHR product in phases – each with specific guidelines, options, and goals – but all within the PACeHR Implementation Framework. The phases – Pilot, Early Adopters, and Full Rollout – are structured to gradually implement the PACeHR EHR products while establishing the implementation and support processes that are needed to implement and manage a high volume of EHR implementations simultaneously over a short time period. The PACeHR Pilot Program will be crafted during the initial PACeHR &acute:new company´ timeframe of July through December 2009, with implementation for the pilot beginning in late December / early January. PACeHR will also use the pilot providers as the marketing and user group nucleus that will be the foundation for PACeHR strategies going forward.

5.4.1 Project Background and Purpose
PACeHR, acting as a broker on behalf of its member subscribers, negotiated group purchases including discounts and other incentives to make EHR-related software, hardware, training, and services affordable and predictable. Through the American Reinvestment and Recovery Act (ARRA) of 2009, significant Federal funding has been committed to assist health care providers that adopt and achieve meaningful use of EHRs. However, to receive this funding support and achieve meaningful use will require resources that not all small to medium size practices have available. PACeHR will provide these resources & support for practices to achieve ´meaningful use´ as defined by the Federal government. To the small and medium size practice, these criteria are critical yet difficult to achieve without ongoing support and guidance.

5.4.2 Pilot Program Scope and Objectives
The PACeHR Pilot Program is in the process of defining, establishing, and testing the pre-implementation and implementation processes and procedures for how multiple organizations (PACeHR, EHR vendors, Support / Managed Services organizations, provider practices) work together to effectively purchase, implement, & maximize EHRs in small to medium size provider practices. The pilot will also use and evaluate externally provided training resources.

The PACeHR Pilot Program has the following goals and objectives:

This Pilot Program will provide critical information on how effective and useful a collaborative approach to EHR implementation is as it has not previously been attempted on a statewide level. PACeHR the organization has aggressive EHR implementation goals, which cannot be met without efficient implementation strategies. The results of the pilot program will drive the implementation strategies applied to the Early Adopter and Full Rollout plans for PACeHR.

5.4.3 Pilot Program Sites
The PACeHR Pilot Program is establishing what needs to occur to implement EHRs on a high-volume scale with a high level of support services at less than market / retail cost. The selection of Pilot sites required interested practices to submit a Nomination Packet and commit to adhere to program requirements. The PACeHR evaluation staff reviewed & presented finalists to the PACeHR Board of Directors for final approval. The first pilots are implementing in the first quarter of 2010.

5.4.4 Pilot Deliverables
The PACeHR Pilot Program is establishing the processes and infrastructure that will be applied by PACeHR as the EHR products and services are solidified and made available on a large scale. The PACeHR Pilot Program deliverables include the initial frameworks for the following:

The Pilots are in the implementation phase; therefore the above deliverables will be updated and refined as lessons are learned. It is expected the pilot will produce significant documents for the above noted information / deliverables. The evaluation process will occur at 6-month increments and the metrics to be used will be defined throughout the pre-implementation process. The pilot will also produce tools and processes needed to manage the PACeHR project on a larger scale. (Appendix I – PACeHR Pilot Mgmt Plan – contains project plans/tools used to manage the Pilot Program.)

5.4.5 Pilot Management
Management of pilot implementations will be two–fold. PACeHR will have responsibility for the overall implementation plan and schedule, and EHR vendors will each manage detailed implementations for their respective organizations. Other PACeHR staff (and workgroup participants) will participate, as will additional resources from external entities that provide EHR pre–implementation services. Once selected, the practices will be oriented to the PACeHR program, plan, and processes and resources will be assigned. Oversight of the pilot program will be the PACeHR Board of Directors.

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