APP EMR Prep Article

8/13/2019 APP EMR Prep Article

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What to do NowBefore You Purchasean EMR System

555 Pierce Road, Suite 195Itasca, IL 60143630.775.1144www.appdesign.com


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What to do Now

Before You Purchase an EMR System

Glenn Susz, BSIT

Julie Janeway, MSA, JD, ABD/PhDKaren Sparks, MBEd

Overview

The health care buzzwords of the moment are electronic medical records (EMR) and electronic healthrecords (EHR). Electronic records are coming fast with the advent of the Presidents StimulusPackage and push to implement EMR/EHR in practices and health care institutions by 2014, and tocreate a functioning, interoperable National Health Information Network beginning in 2016.

The goal here is to create a collaborative health care community where a patients clinical data isavailable to caregivers regardless of the location or source system, in a manner that meets existingsecurity and privacy requirements. The legislation provides incentive payments to physicians whoadopt and utilize EHR, and these bonus payments are tied to the reporting of quality data .Physicians who have a certified EMR/EHR program and who are reporting Medicare qualitymeasures (PQRI) by 2011 or 2012 are eligible for a total bonus payment of $44,000 over five years.Physicians who dont adopt the technology in 2011 or 2012, but comply with the bill language before2015 can receive a total bonus payment of $41,000 over five years. The incentive payments forphysicians will end in 2016 and the penalties for noncompliance will begin in 2015. In 2015, penaltieswill be a 2 percent decrease of the allowed Medicare charges if the eligible professional does notparticipate and e-prescribe.

The bill establishes a program to provide, among other things, education, awareness, access,equipment, and support to medical and health care providers. The legislation also creates the Office

of National Coordinator for Health Information Technology (ONCHIT), which is in charge of thedevelopment and nationwide implementation of an interoperable health information technologyinfrastructure. Under this law ONCHIT will receive a total of $19 billion dollars earmarked for healthIT. ONCHIT will receive $2 billion to fulfill its mission, and the remaining $17 billion will pay the bonusincentives to healthcare providers.

The Secretary of Health and Human Services has been charged to generate the first set of standardscertification criteria, and implementation specifications no later than December 21, 2009. The HHSSecretary will also be submitting a report to Congress in early 2011 detailing the progress of theprogram, actions taken by the government to facilitate the implementation, discussing barriers toimplementation and completion of the mission, and providing recommendations for fulfilling the goals

of the legislation. Regardless of the fact that there is still no real definition of certified EMR/EHRtechnology that will qualify under the stimulus package, or when the actual payment schedule will bereleased for doling out stimulus funds, appropriate preparation for the implementation of EMR/EHR isrequired for success in the medical climate of the near future.

So now you know what all the buzz is about, and why its buzzing, but it still may be helpful tounderstand the difference between an EMR, and EHR, and a PHR. Recently, the National Alliance forHealth Information Technology (NAHIT) established definitions for electronic medical records (EMR)electronic health records (EHR) and personal health records (PHR). In theory, and by definition, there


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is a difference and it should play into any providers clinical software selection. The NAHIT definesEMR, EHR, and PHR as follows:

EMR:The electronic record of health-related information on an individual that is created, gathered,managed, and consulted by licensed clinicians and staff from a single organization who are involvedin the individuals health and care. An EMR is generally a record of a single diagnosis or treatmentprotocol, most likely used by a specialist. Practices that take care of one unique health issue like a

bariatric practice will do well with a stand-alone EMR. Certain specialists may not need informationabout patient history as much as they need specialty-specific workflows and templates, while others,like bariatric physicians and surgeons may need specialized templates and information screens toaccommodate information from a variety of other specialty practitioners such as cardiologistsrheumatologists, and endocrinologists.

EHR: The aggregate electronic record of health-related information of an individual that is createdand gathered cumulatively across more than one health care organization and is managed andconsulted by licensed clinicians and staff involved in the individuals health and care. An EHRprovides a more comprehensive view into a patients health and history by pulling information fromother systems, providing clinical decision support, and alerting providers to health maintenance

requirements. It will help providers report and measure quality indicators for pay-for-performanceincentives.

PHR or ePHR:An electronic, cumulative record of health-related information of an individual drawnfrom multiple sources that is created, gathered, and managed by the individual. The integrity of thedata in the ePHR and control of access to that data is the responsibility of the individual. To be moseffective, a PHR should include cumulative health information ranging from past and current illnesses,treatments, diagnostics tests, health provider contact information, demographics, allergiesprescriptions, and more. Given the nature of the PHR, it is the individuals responsibility to decidewhat information is stored, and who has access to it. Microsofts HealthVault and Google Health aretwo prominent examples of PHRs.

So why is there confusion regarding the use of the terms EMR and EHR? Despite the NAHITdefinitions, the market is still figuring out which definitions to adopt based on common usage andunderstanding, rather than on actual definition. For the purposes of this article, we will be using thecombined term EMR/HER, and discussing EMR/EHRs in the context of the individual bariatricpractice, not in the context of a larger organization such as a hospital, health care system, oreducational institution.

Regardless of the terms being used or misused, the key decision process for selecting an EMR/EHRis to map out your organizations requirements and methodically assess systems against thosecriteria. Justin Barnes, Chairman of the HIMSS Electronic Health Record Association and VP of

Marketing and Government Affairs at Greenway Medical Technologies, believes the future of healthcare IT is interoperability.

Interoperability, or the ability to exchange data with other EMR/EHR programs, and the ability to e-prescribe are key program qualifications for receiving stimulus funds under President Obamas plan.Interoperability is termed enterprise integration in the law and is defined as the electronic linkage ofhealth care providers, health plans, the government and other interested parties to enable electronicexchange and use of health information among all the components in the health care infrastructure inaccordance with applicable law. Interoperability is the ultimate goal to facilitate the National Healthinformation Network, and to provide patients with better continuity of care, and better access to care.


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It is also a key factor in creating more efficient and successful practices that provide better and moreinformed care for patients.

For many bariatric practices to be successful, moving to electronic record keeping will require morethan just selecting a vendor and installing the software. Much has been written about all the benefitsof EMR/EHR and the incentives available from the Economic Stimulus Package. Even without all thehype, bariatric practice decision-makers should internalize the fact that the benefits are real and cost-

effective given the forthcoming stimulus funding.

With all that being said, the problem practices and other health care institutions are encountering isthat there is a head-long rush to install an EMR/EHR program and everyone is getting themselves ina panic. With little guidance on adequate preparation requirements for the selection of a technologyplatform, buyers rush in all willy-nilly and glassy-eyed from seeing the wonders the programs appearto be able to provide, and vendors are simply rubbing their hands with glee.

The reason practitioners are experiencing so many problems with EMR/EHR implementation is thatthey arent prepared and dont really know what they want and need, nor how to make it work forthem. Private practice, fee-for-service physicians are struggling with balancing productivity and

technological advance versus quality of care. Traditionally, patient information is recorded in processnot later, so many physicians and other practitioners are reluctant to get in the electronic medicalrecord game. Additionally, many feel that the use of EMR/EHRs shifts the paradigm from payingattention to the patient to paying attention to the computer. It doesnt have to necessarily be so.

Cost is another major stumbling block with implementation. It has been estimated that purchasingand installing EMR/EHR will cost from $10,000 to over $30,000 per physician, and additionalmaintenance cost of $1,000 to $2,000 per month. Yet vendor costs only account for approximately70% of the expenditure, the rest may come from storage costs, and maintenance fees. Knowingwhere all the costs lie, and whether or not you should be paying extra for them is part of doing yourhomework and making implementation a success.

To gain the most advantage you will need to look at more than the financial cost and features offeredby the EMR/EHR program. You need to look at the Total Cost of Ownershipwhich includes all of thedirect and indirect costs incurred from preparation through implementation, use, and retirement of thesystem. For example, bariatric practices should be looking at the direct financial costs of a wraparound program that includes features like:

Automatic BOLD data entry Scheduling Demographics Patient History, Intake & Registration Patient Communication & Interaction Patient Information & Education Clinical Documentation Office & Procedure Workflow Messaging Document & Data Management E-scripting Billing & Coding Claims Management


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Collections Comprehensive Reporting Administrative Components Voice Dictation Ancillary Product Management Marketing Interfaces Ease of Implementation Adaptive Work Flows Effective, Professional, In-Person Training On-going Technical Support Adaptability Ability to Customize Data Collection and Reporting Internet-Based System Secure Data Storage Privacy & Disaster Recovery Video Service Agreement

Miscellaneous Features

And, bariatric practices should also be looking at indirectcosts associated with things likeimplementation time frames. Consumers should be aware that the average time for fullimplementation of a new EMR/EHR software program runs something like this:

Phase 1: Preparation: 60-90 days. Phase 2: System Selection: 30-90 days Phase 3: Implementation: 45-180 days Phase 4: Post-Implementation: 6-12 months.

So the estimates of the total calendar time from the beginning to the end of the implementation timeframe (not counting Phase 4) is about 135- 360 days (3.5 - 12 months). This is a considerablecommitment of time, and indirectly,money.

Additionally, other time and effort has to be calculated into the Total Cost of Ownership. Practicesshould be aware of the implementation time frame, and its breakdown shows that EMR/EHRprograms are not simply fix-all programs that can be purchased and implemented in a completelyturn-key manner. With proper preparation, planning, and technology selection, the Total Cost ofOwnershipcan be appropriately managed and better controlled, and many of the barriers toimplementation can be avoided.

With this in mind, what is needed is an understanding of what to do beforethe purchase decision ismade. This guide will prepare you for a smooth implementation and a total understanding of the costand effort required to successfully implement a new EMR/EHR program in your office.

Start by doing a complete assessment of all the factors. This will help you and other decision makersto understand the mind set of EMR/EHR implementation, how people will interact with the system, therequired organizational habits and changes, as well as employees ability and willingness to change.

A simple approach to starting an assessment is to group issues and concerns for review by the


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following categories: practice goals, people, process, and technology. This will help you to assessthe true cost and effort of installing an EMR/EHR. These groups can be summarized as follows:

Practice goals The direction and business objectives of the practice. Without a clear picture ofwhere the practice is now, and where it is heading, appropriate process, business, finance, andtechnology planning cannot take place. Do you want to stay small? Do you want to have severallocations? Do you want to add physicians? Do you want to expand the service lines offered? Do

you want to franchise? Do you want to change locations or premises to a bigger or smaller space?These are the types of questions that must be explored in this category.

People Organizational structure; human capital management; leadership development; recruiting;performance management; and training and development. This involves exploring all the key issuesrelated to employee and staff involvement and interaction with the recordkeeping and datamanagement process.

Process The business activities performed by the enterprise - includes associated sequence, rules,data, service lines, workflow, and metrics information. A process can be defined as starting with atrigger event that creates a chain of actions that will result in something being prepared for a

patient/customer of that process. Focusing on high frequency transactions can be of significantbenefit to the standardization of the process, but remember that examination of the non-standardtransactions (where service may be slipping most or the potential for significant failure in the processmay exist) can provide significant benefit to the standardization and improvement of the process aswell. In short, know the strengths and weaknesses of your current information collection anddissemination process. You have to look at improving the way you do business, not just automatingwhat you already do that isnt really working anyway. If you automate a bad system, all you are doingis adding a technological component to an already bad system. Then it becomes easy to blame theprogram and continue to ignore the process.

Technology Data, applications, hardware, and technical infrastructure to achieve the practices

goals. Now that you know where you want to go, what you want to achieve, people and manpowerissues are clear, and the process is developed and refined, technology can be introduced to ensureconsistency in application of the process, and to provide the thin guiding rails to keep the process ontrack. The technology is only as good as the underlying process.

Below is a basic checklist for your office to use in preparation for transition to EMR/EHR.

PRACTICE GOALS

Practice Direction What do you want to achieve with the practice?

In what direction do you want to take the practice? Over what time period do you wish to achieve these goals? What tools and assistance will you need to achieve these goals? How big does your practice want to be? How fast are you growing? How fast do you want to grow? Is there a plan to add other physicians to the practice? What level of involvement are you willing to accept from outside resources to achieve your

goals? What is your patient demographic?


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Do you want to have ancillary service lines? Do you sell, or want to sell ancillary products in the practice?

PEOPLE

Employee Involvement Who will be involved in the process? What are their roles? How do they work together? Do they have the requisite technological abilities to do the job? Do they have the requisite educational abilities to do the job (coding, billing, etc.) Do you have sufficient employees to ensure coverage at all times?

Current Employee Skill Set Is your staff computer literate? Are they comfortable using computers? Will added staff or temp staff be required for data entry or use of the software? Can they use any computer programs besides word processing?

Software Training Regardless of your staffs computer skills, time will be needed to train them inthe use of the EMR. Can this be done during office hours, or will arrangements need to be made for afterhours, or

off-site training? Will they require additional training based on their skill level? Are they willing to participate in additional training?

Defined Roles & Responsibilities Who will own the various processes? Who will have responsibility for the planning, implementation, and performance?

Who will manage the process? Are the current roles and responsibilities properly assigned for an efficient

process? Will job duties have to be rearranged or reassigned upon EMR/EHR

implementation? Will the process insure the doctor is informed but is not required for day-to day operations? Who will be responsible for ensuring the doctor stays informed.

Commitment & Buy-In You and your staff will need to be completely committed to the changesrequired by an EMR/EHR implementation. What are the current attitudes toward EMR/EHR implementation?

Are the key employees committed to improving the system and working together? Are they prepared to do the work to fix any problem?

Patient Volume and Office Size Two simple items to be aware of are quantity of patients yourpractice services, and the staff using or having access to the software. Many software packagespurchase price and/or license fees are based on various factors such as the number of patientstracked by the software, or number of physicians using the software. How many physicians are in your practice? Will they all be using the software? How many patients are in the practice?


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What is the patient growth rate expected in the practice in the next year, 2 years, 5 years?

Patient Demographics Many EMR/EHRs offer a patient interface or portal, and utilize integratedpatient email notification and reporting. These features can greatly benefit your practice, but only tothe extent that they are, or can be used by your patient audience. What is the average age of your patient population? How computer literate and comfortable is your patient population?

Is anyone in your practice willing or able to teach patients how to use the patient portal? Do you have a back-up plan for patients who cannot or will not use the patient portal?

Time Frame Have you scheduled adequate time for appropriate preparation prior to program selection? Have you considered or planned for the actual time it will take to implement, convert, train, and

reach the point of effective usage?

PROCESS

Business Processes and Workflow Software companies typically incorporate best practiceprocesses into their products. Modifying your processes to work with the software may improve yourprocesses. On the other side of the coin, a thorough understanding of your current processes canhelp you make better technology decisions. Do you plan to automate your existing processes, or do you plan to adapt your processes to

the EMR? Will your paper flow adapt to the EMR? Is your process sufficient for your current and planned patient volume and business direction? Have you reviewed the most common transactions in the process for any opportunity for

improvement? Have you reviewed the least common, non-standard, or unusual transactions in the process for

any opportunity for improvement? Can the efficiency of your entire process be improved? What are the strengths and weaknesses of your process? Where might improvement be made with the utilization of an EMR/EHR?

Security & Access Most practices already have some form of security procedures in placeregarding access and dissemination of sensitive information. But with the ease of viewing, copying,printing, and forwarding information on computers you may be required to modify or enhance yourprocedures, both for electronic access as well as access to the facility. Do you currently have data security measures? Do you currently have premises security measures?

Are the existing security measures sufficient or do they need to be enhanced? Do you have HIPAA measures in place to guard against the inadvertent release or disclosure

of sensitive patient information? Will security measures have to change with the implementation of an EMR/EHR program?

Internet Use Policy You may already have a computer on each employees desk that is connectedto the internet. You should have an internal policy for internet use and not just during work hours. Do you have an internet use policy for work and non-work hours? Does your use policy cover non-business and inappropriate use? Do you have procedures in place to be able to monitor and enforce the policy?


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Business Continuity / Disaster Recovery Plan You will need to insure that the software and yourprocedures allow you to meet mandated regulations regarding safekeeping and loss of data. Inaddition to that, you will also want to be able to define acceptable data loss or system outage todetermine Recovery Time Objective(RTO) and Recovery Point Objective(RPO). These will help indesigning your back-up strategy and network infrastructure. You may be meeting governmentregulations, but could still suffer a substantial loss of business and/or revenue without a BC/DR plan.

Do you currently have a business continuity/disaster recovery plan? Will your current plan still be appropriate with the implementation of an EMR/EHR program?

Measureable Metrics - It will help to determine project success if you can set some Critical SuccessFactors (CFS) and measurable metrics to track improvement in time savings, dollar savings, patientconversion, patient compliance, use of the EMR/EHR, and other factors. How do you currently measure success and progress? How can you improve the process? What are your critical success factors? Do they align with your practice goals and objectives? If you will create new critical success factors after implementation of an EMR/EHR program,

how will you measure them?

TECHNOLOGY

SaaS/Hosted Solution vs. Client/Server You will need to understand the pros and cons of a web-based, Software as a Service(SaaS) hosted solution versus a traditional In-House system. Hostedsolutions are less likely to have post-installation problems and generally have lowercapitalexpenditures. They also usually eliminate concerns over upgrades and obsoleteness; however, youshould be aware that some vendors offer a scaled-down version from its client/server version. If youpurchase such an option, be sure to obtain rights to the software code in case the vendor becomes

insolvent or goes out of business. Your decision here will impact other technical aspects of thenetwork hardware, installation, and some procedures.

Workstations Once the office goes electronic: Will there be enough workstations to support the day-to-day business operations? Are the current workstations adequate to support the software in terms of memory, storage

and performance as well as operating system (OS) version? Will upgrades and/or replacements be required? Is there enough physical space to put a workstation where it is needed? Do you need to purchase any other accessory items like webcams, microphones, etc.? Is the software best utilized through the use of a particular type of hardware (tablet with

docking stations, system with built-in webcam and microphone, specific memory or graphicsrequirements, etc.)?

Do you have sufficient electrical service and outlets for all of the workstations and equipment?

Software Compatibility The EMR/EHR software should integrate with existing in-house softwaresuch as accounting, billing, and CRM applications, or you may not get the increase in efficiencies andmaximum benefit from the system. This could also impact your workflow processes. Are your current software applications up-to-date? Are your current software applications of a standard nature, or are they custom applications?


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External Connectivity Do you have requirements that the EMR/EHR software connect to external third parties

systems such as hospital EHR systems, Regional Health Information Organizations(RHIO)and Health Information Exchanges(HIE), the Center for Disease Control(CDC), BOLD, orPHRs such as Google Health, Microsoft HealthVault, or WebMD?

Is an EMR or EHR more appropriate for your organization?

Network Infrastructure Above and beyond the cost of the software and workstations, you will needto understand any additional required changes to your network. Will you need Internet access? If you currently have access, is the bandwidth sufficient to support the new software and

operations? Do you have a firewall that supports your Internet Use and Security Policy? Will you need redundant servers or Internet providers to support your defined Business

Continuity /Disaster Recovery Plan? Does the program integrate with your web site?

Data Migration/Conversion

Have you considered the cost, time, and effort to convert existing patient data into the newsystem?

Depending on the EMR/EHR, can the information be imported into the new systemelectronically, or will it have to be manually entered?

Will documents have to be scanned and uploaded into the new system? Does the new system have fields or buckets for particular data you collect on a patient? Will the new EMR/EHR system electronically import data from a previously employed

EMR/EHR system?

Training Does the EMR/EHR vendor provide training?

In what form is the training provided? (Internet, written training manual, in-person training by aprofessional technology trainer)

How long will they provide training? What level of training is provided (basic, basic through intermediate, advanced)? Is training included in the price, or is it a separate charge? Is the training limited to a certain number of individuals in the practice? If the training is an additional cost, is it on a per session or per person basis?

Technical Support The vendor from whom you purchase the EMR/EHR will most likely supporttheir product, but you will need to have someone else available to support your workstations, printers,email, and network.

Do you have hardware and internet provider support available? Do you have warranties on your hardware?

Summary

As you can see from the items listed above, there is a fair amount of effort and planning to be doneinorder to create yourpractices IT strategy. In the IT sector, the general consensus is that if you waitto implement your EMR/EHR program you will be behind and probably won't qualify for the maximumreimbursement provided in the stimulus package. According to Charles Christian, Director ofInformation Systems and CIO at Good Samaritan Hospital in southwest Indiana, "It's not time to


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panic, but it is also not time to procrastinate. We are expected to do the work and show the outcomeof that work before we get a nickel."

With the 2011 deadline for the first stimulus package pay-out approaching, now is the time to startyour assessment and planning in order to be ready to maximize your federal rebate for an EMRpurchase, and benefit your practice and your patients. Often businesses don't want to take the timeto properly analyze their requirements, goals and objectives before they embark on new projects. But

can you afford notto take the time? Either you invest the time, effort, and money up front to get theright solutions, or you pay later for maintenance costs, ineffective operations, poor employee morale,an inability to make effective decisions, impaired success of the practice, and a negative effect onpatient care. Its your call.

REFERENCES

NAHIT; http://www.nahit.org/

N Engl J Med.2009;360(15):14771479; http://www.medscape.com/viewarticle/590855

CNSNews; http://www.cnsnews.com/public/Content/Article.aspx?rsrcid=43715

HIMSS Electronic Health Record Association;http://www.healthleadersmedia.com/content/231473/topic/WS_HLM2_TEC/HIMSS09-Recap-Stimulus-Interoperability-and-More.html

Articlebase; http://www.articlesbase.com/ecommerce-articles/the-people-process-technology-puzzle-32788.html

Glenn Susz is VP of Business Development at APP Design, a software development companydelivering innovative software solutions for such firmsas Baker & McKenzie, Boise Cascade,

WNYHealtheNet, Independent Health, HealthXnet, Mediware, and the first community healthcarenetworks: the Wisconsin Healthcare Information Network, Western New York HealtheNet , andHealthcare Extranets of New Mexico. He has over 25 years of IT consulting experience in theHealthcare, Financial Services, Securities & Commodities, and Education communities ranging fromstart-ups to Fortune 500 companies. Glenns business mantra centers on three words: experience,excellence, and commitment. Glenn can be contacted at: http://www.appdesign.com;[email protected]

Julie Janeway and Karen Sparks are the owners of LV Medical/Legal Consulting & Training,specializing in bariatrics and lifestyle medicine practice issues. Julie and Karen have extensive

background and experience in bariatric practice and program consulting. They consult and train forpractices, professional associations, and industry partners across North America. They are theauthors of the number one weight loss surgery patient education book in the world: The REALSkinny on Weight Loss Surgery: A Practical Guide to What You Can REALLY Expect!, They are alsomajor contributing authors of the Encyclopedia of Obesityand contributing authors of Weight LossSurgery: A Multidisciplinary Approach. Julie and Karen also have two other medical textbooksforthcoming. Let LV Medical/Legal Consulting & Training assist you in moving toward greatersuccess. Remember, a person who graduated yesterday, and stops learning today, is uneducatedtomorrow. Julie and Karen can be contacted at www.lvmedicaltraining.com;

[email protected]


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