5.6 Goals Achieved/Not Achieved
The overarching
mission of this phase of the Transformation Grant was to develop and implement
a web based electronic health record for AHCCCS providers.
5.6.1 Achieved
There were many milestones along the
way that contributed to the ultimate formation of PACeHR as a non-profit
corporation to accelerate the adoption of EHRs
Goals achieved included:
5.6.2 Not Achieved
The achievements of PACeHR are
substantial; however, some of the goals and objectives did not progress as far
as the PACeHR Team had planned. Goals that were in progress, but not achieved
include
5.7.1 Importance of Managing Scope
The scope of health
information technology is vast and includes far more than the three phases of
HIE, clinical data repository, and EHR implementation selected for the
Transformation Grant. Given.
In order to manage the scope, the PACeHR Team solicited information from EHR customers and stakeholders to determine which critical components to include. The process of developing a collaborative requesting community and stakeholder input, developing request for proposal and evaluation processes, formation of a non-profit corporation, and implementation of pilot sites was a massive undertaking. Such a large endeavor carries much potential for obstacles to contribute to delays and substantially affect progress. It is crucial to define clear boundaries and direction for the project in order for all a priori identified deliverables to be appropriately funded.
5.7.2 Business Lessons
The assembled Team must have a
health information technology, EHR, AND physician perspective.
Business processes that ensure efficiency are important because partners, client organizations, and corporations may have disparate interests. Processes must be constructed to hold all parties highly accountable for projects and timelines.
Selected vendors must have documented implementation experience.
Because small/medium physician offices are cash constrained, a service organization such as PACeHR must operate with the utmost efficiency in order to bring services to a price point that is consumable and valuable to the market.
The processes required to construct legal agreements consumes much of the time and money resources. These contracts are vital to the success of PACeHR and there must be no ambiguity in the details and subtleties. Contracts exist between PACeHR and vendors, in addition to vendors and PACeHR, and customers agree to contracts with PACeHR and vendors. It is important to understand a service revenue model prior to solidifying master agreements with the EHR vendor community
PACeHR must partner with qualified companies that provide critical expertise not available internally.
When developing or refining a service offer within PACeHR, services must not overlap with vendor core competencies (e.g. core EHR implementation, training and project management services are effectively done by EHR vendors and would be overlay/redundant services by PACeHR.) Redundant services results in inefficiency and confuses clients.
5.7.3 EHR Implementation Lessons
There is a lack of
knowledge of EHR value and how it applies to a practice across Arizona as
reinforced by the statistic that nearly 7,000 primary care specialists in
Arizona do NOT use an EHR. This indicates that there are many barriers and
workflow issues and additional education necessary to move a practice to
meaningful use. In addition to fitting an EHR into the process of an office,
the specific technical functions of the EHR are important to workflow and may
vary from specialty to specialty.
The following are lessons learned about practices and their characteristics:
Physician offices often lack basic understanding of EHRs. They may believe the need to deploy EHRs exists and may have peers using an EHR but lack comprehension of workflow change necessary to move from paper to paperless. Educating and readying the small/medium physician office on EHR selection options and possible outcome of effectively using an EHR is critical.
Practices want a trusted resource to help in the EHR decision / procurement process and they want subsidized hardware and assistance with training and support.
It is important to evaluate specialty specific content and the depth of content with the EHR vendor applications; for example, specialty obstetrics and gynecology practices require additional content that primary care may not.
It is important to balance client needs versus services that they can afford. Servicing small/medium physician offices has complexities. They may be geographically disparate, lack funding, or have financing challenges. Additionally, an office may lack additional staff necessary to support evaluations, implementation, project management, or supporting IT resources. While service offers can be created, the price point of the services must be carefully evaluated and packaged in collaboration with the EHR vendors and IT service partner.
Practices must adjust their patient workload to free up resources and time to appropriately support the requirements of the EHR vendor.
Standardized data entry is critical to expedite data sharing across entities going forward.
5.7.4 Technology Lessons
CMS is starting to move
states towards a standards-based, modern IT architecture that can link data
from a variety of sources – from Medicaid claims to long-term care
records to test orders & results. Standards are vital to interoperability
as they enable vendors to build their systems to be interoperable. They encode
health information using a common "language" that multiple systems
can read.
Other technology lessons to consider include EHR capabilities:
While an electronic exchange of information across facilities needs the above to share information, many types of EHRs exist. The needs and goals of the provider must drive product selection.
5.8 National Implications
The call for widespread
implementation of EHRs to improve health information sharing, health care
safety, quality, and cost is evidenced by HITECH legislation and ARRA
incentives. Evidence to support implementation originates from cost and safety
data. At current rates, state Medicaid agencies will collectively be
responsible for $250 billion in 2014, twice the current contribution.2
Leveraging cutting-edge health information technology is expected to transform
the medical system, improve efficiencies, and decrease costs.
Today, healthcare is slow, cumbersome, fragmented, & expensive, which makes efficient use of limited resources difficult. To change this environment, information is needed to better understand and quantify the more prevalent & significant issues that have impacted or contributed to the spiraling cost.
PACeHR contributed and continues to contribute to the cost and quality solutions through efforts to encourage and accelerate EHR adoption in small to medium sized practices. Of particular note on the National level: processes that PACeHR used and continues to use are replicable not only due to documentation, but because the process is relevant to all states. Of key importance in the process is involving all stakeholders including the vendors and payors. Vendor selection is key to data exchange and payor involvement
5.9 Policy Findings
See Phase 1, Health Information
Exchange Section 3.9 that describes the examination of Arizona State and
Federal statutes and regulations to determine existing law provides barriers to
HIT. The statutes and laws examined include:
Inconsistencies with identified statutes and laws are identified in Phase 1: Health Information Exchange Section 3.9.
In support of Ambulatory EHRs for areas such as Meaningful Use support and to ensure compliance to EHR standards and meet evolving rules and regulations, PACeHR required that vendors be certified by the Certification Commission for Health Information Technology (CCHIT), a nonprofit, 501(c)3 organization with the public mission of accelerating the adoption of health IT. The CCHIT certification criteria were developed through a voluntary, consensus-based process engaging diverse stakeholders, and the Certification Commission was officially recognized by the Federal government as a certifying body. To become CCHIT certified, products undergo a rigorous comprehensive evaluation for EHR systems that enables providers to meet all meaningful use objectives. Products must significantly exceed minimum Federal standards requirements, are rated for usability, and are verified to be in successful use at multiple sites. This program addresses the needs of providers and hospitals who want maximal assurance of EHR capabilities and compliance.
On December 31st, 2009 CMS announced their Stage 1 Meaningful Use criteria. This information, coupled with CCHIT, will be utilized going forward.
5.10 Impact to Medicaid
Providers have utilized EHRs
since the 1990´s, and the technology has made huge strides in ease of use
and affordability. The importance of EHRs is acknowledged by almost all 50
states as most have already initiated some electronic health strategies.
EHR benefits to Medicaid include improved quality of care, reduction in duplication of tests & services, & the prevention of chronic disease & unnecessary hospitalizations resulting from medical errors & unattended diseases - all achieved through the sharing of good data. Providers initially gain value through office efficiencies (enhanced workflows, decreased paperwork) and improved decision-making options at the point of care while positioning themselves for quality reporting & pay for performance programs.
Constant pressures to reduce costs & improve quality care increase the need for well-managed data. Medicaid, with their providers, can use EHRs to exchange patient data through an interoperable infrastructure that enables:
Streamlined workflows such as on-line appointment scheduling can help providers build better patient compliance & relationships and make monitoring of health status & events easier. These tools also capture quality data and can eliminate or reduce phone calls to and from the front office staff.
Additionally, there is enterprise-level value for those organizations that more aggressively use the analytical component of the EHR through:
PACeHR´s commitment to facilitate the adoption of EHRs to small and medium size practice providers will enable these providers to achieve the above benefits, which will impact Medicaid as more practitioners become connected. Medicaid, patients and their providers, and public health will all share in the benefit provided by improved data management and sharing.
5.11 Cost Efficiencies and Savings
Cost efficiencies
may be illustrated with a sample visit to a medical provider. In most cases,
the visit generates a stack of paper documents with a subset of a
patient´s actual health history. Most likely, the history is not 100%
accurate, complete, or even legible. While each office has their own forms
& format / process for data capture, it´s essentially the same
information collected across providers captured on paper from the patient while
in the waiting room. Once returned to the office staff, the papers are added to
a patient´s chart – another paper folder, which may be reviewed
& then given to the provider.
This process repeats itself as the patient, & hopefully their chart, works its way through the clinicians & administrative personnel to be changed, updated, reviewed, copied, etc. If a script or test is required, another paper-generated process ensues, & may require handling by multiple staff to capture all the latest treatment/coverage information. If another provider calls re: the same patient, the chart must be found & the process repeats, often making the chart unavailable for treatment purposes. This disjointed process prevents providers from using timely, accurate data for high quality patient care in a cost efficient manner.
EHRs support quality information that is readily available before a medical treatment decision is made. EHRs produce this change so when the patient enters the provider´s office, the power of the EHR has already provided the bulk of their health history, plus the following, in minutes vs. hours or days:
EHRs provide cost efficiencies and savings. While it can be difficult to fully quantify, Medicaid data may contain duplicate prescriptions, unnecessary & repetitive tests, fraudulent claims due to inaccurate eligibility data, & lack of access to recent patient histories as factors that increased costs. This information supports using EHRs to meet National Medicaid performance targets of and annual decreases in administrative and clinical costs of two to three percent. EHRs contribute to this goal with
EHR systems that include computerized ordering functionality & decision support tools may decrease medication, lab, and radiology costs from reduced occurrences of office visits & hospitalizations if they help alleviate adverse drug events. While most of the savings noted to date are through the electronic prescribing function, the trickle-down effect of poor medication choices generate events that affect the other arenas – these are simply more difficult to isolate & quantify.
Evidence of hard-dollar savings from EHRs is not available due to the newness of the technology, the immaturity of the market, & the slow adoption rate. However, the savings opportunities identified from available research are generally accepted as viable savings opportunities.
A commitment to assisting physician offices achieve meaningful use will help qualify them for the CMS incentives,, and can be accomplished by ensuring the criteria in the Meaningful Use Matrix for the physician office Stage one are met. The stage criteria was formally release Dec 30, 2009; however, PACeHR was committed to tracking to the standard and developed supporting contractual relationships with our preferred EHR vendors such that they support the Meaningful Objectives and that the EHR applications support within their the applications clinical workflow the physician´s ability to effectively get alerts and capture the necessary data.
Finally, some factors that influence Medicaid´s ability to achieve its goals include current level of prescription management and EHR penetration rate, as well as the population´s ´access to care´ patterns & demographics. Widespread adoption of EHRs is needed to meet these goals and enable providers to deliver better access to higher quality care at a reasonable price. EHRs can use data electronically captured to pinpoint and measure where achievements occur, identify where progress made or is needed, and where rewardsor incentives can be applied.
5.12 Sustainability
PACeHR developed a detailed
business model described in the Business Plan. PACeHR will be a subscription
and consulting service fee model with various fee-based subscribers and
members. The financial plan for PACeHR includes the Start-Up Phase of July
— December, 2009, then Fiscal Years 1 and 2 with a fiscal year of January
— December beginning in 2010.
The market dynamic of Electronic Healthcare Information Technology (HIT) targeted towards the ambulatory physician office is rapidly evolving. Therefore, PAceHR´s business model has also evolved. Initially, it was thought that PACeHR would achieve sustainability as a result of several key assumptions:
The above agreement negotiations have been protracted. As a result, it is evident that the PACeHR business plan must rapidly evolve to include a client base beyond the Arizona REC and that additional service offerings that target the healthcare ecosystem (Hospitals, Payors, EHR Vendors and Physician offices) must be refined and developed.
Accelerating EHR adoption within primary care small and medium-sized physician practices is the immediate focus. PACeHR performed a needs analysis described in Section 5.2.1 to ensure that their product aligns with market demand. PACeHR designed its services to meet requested needs of practices and believes that this strategy will contribute to sustainability. Services provided by PACeHR and supporting strategic partners include:
To develop services that ensure PACeHR addresses provider demand, PACeHR will focus on the physician office as the center point in the healthcare ecosystem, which reaches payers, data sharing, centers, hospitals/acute care facilities, laboratories and imaging centers, and referring practices. PACeHR, with its partners, will work to foster vision, collaboration, and tactical efforts in support of successful adoption, meaningful use and communication throughout the system.