AHCCCS - 2007 Medicaid Transformation Grant Final Report

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

• More than 75% of physicians utilize paper based medical records
• More than 41% of physicians use some form of an electronic system for storing medical records
• Approximately nine percent (9%) of physicians in Arizona utilize a fully functional EMR
• The highest usage of EMRs occurs in government settings as compared to the lowest in private solo practices.
• Paper files remain the dominant form of medical records; only one-fourth of physicians have eliminated the use of paper medical records.

• Cost was listed as the number one barrier to adoption of an EMR
• Additional barriers include: time/training, insufficient return on investment, lack of interoperability, and attitude
• Approximately one in five physicians in Arizona does not have internet access in their practice setting
• Physician characteristics – the odds that a physician will use an EMR consistently and significantly decreases when evaluating utilization by prescriber age categories. Utilization is higher in younger prescribers.

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.

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

• Characteristics of such a program need include a solid product that is affordable, has predictable expenses, requires minimal maintenance, and includes performance oversight if web-based.
• Electronic health record (EHR) requirements for a statewide system were defined in a request for information (Standardized Inquiry).

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

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

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:

• Affordable monthly subscription through a standard contract
• Tiered rates for part time providers, students and clinicians in training
• Interfaces with core services providers
• Planning, selection, set-up, training, and implementation aid
• Facilitated user forum and peer assist program
• Standard and ad-hoc reporting modules
• Discounted hardware, software and other support arrangements
• Master Agreements / contracts across EHR vendors and IT partners

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:

• Multi-level Weighted Scoring Process – outlined the process to score each proposal response based on the importance / value of each requirement. Requirements were categorized by minimum criteria and core criteria.
• Minimum Entrance Criteria – 2 levels needed to be met before a full evaluation would be conducted. These scores were compiled and those that met the criteria graduated to the full review process.
• Detailed Scoring Tools and Process – each evaluator rated the responses provided by the EHR vendor, compared them to another evaluator’s rating, and subsequently the consensus of those evaluations were recorded and brought forward to the full Evaluation Panel for review & analysis.
• Technical Scoring Analysis – a separate analysis tool was created to specifically evaluate the technical aspect of each proposal. The same process was followed here as for the Detailed Scoring Tools and Process but it was separated for a specialized pool of initial reviewers.
• Financial Viability Factors – criteria used to determine financially sound companies that included a financial due diligence process
• Reference Checking Process – responses to an established set of questions / evaluation criteria were verified (responses were documented in a set format for consistency)
• Pricing Analysis – used to compare costs of key components across EHR vendor proposals
• Community Forums / Product Demonstrations – required each vendor finalist to present their system per a pre-established script and provided an evaluation form for attendees.

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

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:

• Goal 1: Establish and validate the implementation processes for implementation of a PACeHR EHR.
  • Develop the PACeHR pre-implementation and implementation processes & tools to prepare a provider practice for their EHR implementation through the PACeHR program.
  • Construct a standard implementation cycle and timeline for implementation activities that can be applied as the framework for future implementations.
  • Implement a PACeHR EHR in 5-10 small to medium size primary care practices in at least two Arizona counties by 1Q10.

• Goal 2: Obtain success stories for marketing campaigns.
  • Capture the implementation challenges and the actions taken to achieve successful implementations by 100% of the pilot practices.
  • Convert the successes into applications that can be taught in future implementations and used to teach future practices.

• Goal 3: Create implementation baseline metrics
  • Identify core implementation and project metrics to assess implementation timelines and processes & key measurements needed for the practices.

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:

• Pilot Practice Pre–Implementation Plan (site visit schedule, define the PACeHR assessment processes & tools – workflow assessment, staff readiness review, IT assessment plan; infrastructure procurement, Pilot Site Summary Analysis Report – will become an ongoing collection of practice observations, notes, feedback, etc.)
• Pilot Practice Implementation Plan (post–assessment, detailed implementation schedule each practice will use to define their activities and timelines for implementation – how to actually implement the EHR & associated tools to prep the practice for Go–Live)
• Tools / Process to apply for external funding resources (how to expedite the application process, tracking of results, reporting requirements to prove accomplishments)
• Staffing plan (what resources are needed, how to develop / secure them, responsibilities of each)
• Pilot user group network (pilots using one another as information / process resources and support)
• PACeHR ´How To´ Manual (collection of forms – contracts, agreements; information, plans, processes, requirements, etc. to participate in PACeHR)
• Training plan (change management, system training, workflow re–design)
• Ongoing support and maintenance approach to enable the practices to work towards, and to achieve, meaningful use
• Evaluation process / plan (metrics to determine successes, process / tool improvements needed)

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.

To Section 5.5