SAAS National Conference & NIATx Summit

July 11, 2010

Pre-Conference Workshop

Implementing

Electronic Behavioral Health Records:

Understanding Key Issues & Barriers

– Session I –

Terminology, Business Case, Readiness

‘‘The current paper medical record is insufficient in content, format, accuracy, and accessibility to allow determination of

health care effectiveness and outcomes.’’

The American Medical Association

ObjectiveTo position you for guiding electronic behavioral health records (EbHR) implementation by:

1.Learning how EbHR aligns with your organization;

2.Learning how EbHR impacts your organization;

3.Learning how EbHR was implemented by others; and

4.Developing your EbHR message & plan.

Agenda8:30am – 8:45am Introduction

8:45am – 10:15am Basics: Terminology, Business Case, Readiness

10:15am – 10:30am Break (206)

10:30am – 12:00pm Impact: Trust & Relationships12:00pm – 1:00pm Lunch (206)

1:00pm – 2:30pm How: Learning from Experts2:30pm – 2:45pm Break (206)

2:45pm – 4:15pm Taking Action: Developing Your Message & Plan

4:15pm – 4:30pm Wrap-up

Your Presenters Dr. Jay Ford

NIATx, Director of ResearchPhD Industrial EngineeringDirector of Researchjay.ford@chess.wisc.edu

Matt M. McCluskeyEHR & Process Improvement ConsultantMS Healthcare Systems Engineering, MBA General

Business, Leadership, Strategymmmccluskey@gmail.com

Our AudienceYour name & job titleYour employer name & locationYour experience & knowledge (EbHR)

Terminology

“The health IT terminology problem is not a lack of definition

for the records and network terms, but rather, the existence of too many differing and even

conflicting definitions.”

National Alliance for Health Information Technology. Report to ONC: Defining Key HIT Terms. April 28, 2008

Health Information Technology (HIT)

The application of information processing involving both computer hardware and software that stores, retrieves, shares, and/or uses healthcare information, data, and knowledge for communication and decision-making.

Health & Human Services (HHS). Glossary of Selected Terms Related to Health IT. healthit.hhs.gov. July 5, 2010.

Electronic Medical Records (EMR)

An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one

health care organization.

National Alliance for Health Information Technology. Report to ONC: Defining Key HIT Terms. April 28, 2008

Electronic Health Records (EHR)

An electronic record of health-related information on an individual that:

1. conforms to nationally recognized interoperability standards and

2. can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.

National Alliance for Health Information Technology. Report to ONC: Defining Key HIT Terms. April 28, 2008

Association for Healthcare Research & Quality (AHRQ). healthit.ahrq.gov. July 5, 2010.

Health Information Exchange…

The sharing of clinical and administrative data across the boundaries of health care institutions, health data

repositories, and States.

Electronic Behavioral Health Records (EbHR)

An electronic record of behavioral health-related information on an individual that:

1. conforms to nationally recognized interoperability standards and

2. can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.

Electronic Practice Management (EPM)

That function of the medical office record which contains financial, demographic and non-medical information about

patients.

Other names…Practice Management System (PMS)Enterprise Management System (EMS)Executive Information System (EIS)

West Virginia Medical Foundation. Glossary of HIT Terms. 2007.

Personal Health Record (PHR)

An electronic application through which individuals maintain and manage their health information (and that of others for whom they are authorized) in a private, secure,

and confidential environment.

Health & Human Services (HHS). Glossary of Selected Terms Related to Health IT. healthit.hhs.gov. July 5, 2010.

Federal Policy

Federal PolicyBackground (HITECH Act)Leadership (ONC) & ResourcesIncentive Programs

Medicare & Medicaid (H.R. 5040) Meaningful UseCertified technology

Background American Recovery & Reinvestment Act (ARRA) of 2009

(Recovery Act)Obama signed into law February 17, 2009Health Information Technology for Economic & Clinical

Health (HITECH) Act ARRA Div. A Title XIII & Div. B Title IVAuthorizes the CMS to provide $20 billion HIT

reimbursement incentives

HHS. 45 CFR Part 170 Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health

Record Technology; Interim Final Rule. January 13, 2010.

H.R. 5040 HITECH Extension for Behavioral Health Services Act of 2010

(H.R. 5040)Patrick Kennedy (D-RI) & Tim Murphy (R-PA)Referred on April 15, 2010 (Committees Energy & Commerce,

Ways & Means)Make addiction & mental health services eligible for $15 mil HIT

funds (0.075%)Uses…

Facilitate the purchase and enhance the use of HITTrain personnel in the use of HITImprove the secure HIE among providers (including primary

care)Improve HIT for adaptation to community-based behavioral

health settingsAssist with the implementation of telemedicineCollaborate and integrate with HIT regional extension centers

The Library of Congress (THOMAS). thomas.loc.gov. July 5, 2010.

Leadership & Resources Health & Human Services (HHS) – Kathleen Sebelius Office of the National Coordinator (ONC) – David

Blumenthal MD, MPP Centers for Medicare & Medicaid Services (CMS) Health Information Technology Policy Committee Health Information Technology Standards Committee National eHealth Collaborative Health Information Technology Standards Panel (HITSP) National Institute of Standards Technology (NIST) Certification Commission of Health Information

Technology (CCHIT) Regional Extension Centers

Incentive Programs: Medicare Medicare Fee-for-Service & Medicare Advantage EHR Incentive

ProgramEligibility

Professionals (EP), Hospitals, Critical Access Hospital (CAH)Doctors of medicine or osteopathyDoctors of dental surgery or dental medicineDoctors of podiatric medicineDoctors of optometryChiropractors

PaymentEP: $44,000 per physician (max) between 2011 and 2016Hospitals: Medicare share, initial amount, other

PenaltyMedicare fee schedule incremental reduction (1% - 5%)

after 2015HHS. 45 CFR Part 170 Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health

Record Technology; Interim Final Rule. January 13, 2010.

Incentive Programs: Medicaid Medicaid EHR Incentive Program

EligibilityFQHC & RHC Professionals (EP), Children’s & Acute

Care HospitalsPhysiciansDentistsCertified nurse-midwivesNurse practitionersPhysician assistants

PaymentEP: $63,750 per physician (max) over 6 yearsHospitals: EHR total cost, Medicaid share

PenaltyNot Applicable

HHS. 45 CFR Part 170 Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health

Record Technology; Interim Final Rule. January 13, 2010.

Meaningful UseAn eligible professional or hospital shall be considered a meaningful EHR user for an EHR reporting period for a payment year if they meet the following 3 requirements:

1.Demonstrates use of certified EHR technology in a meaningful manner;

2.Demonstrates to the satisfaction of the Secretary that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care such as promoting care coordination, in accordance with all laws and standards applicable to the exchange of information; and

3.Using its certified EHR technology, submits to the Secretary, in a form and manner specified by the Secretary, information on clinical quality measures and other measures specified by the Secretary.

HHS. 45 CFR Part 170 Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health

Record Technology; Interim Final Rule. January 13, 2010.

Certified EHR

A complete EHR or a combination of modules, each of which:

1.meets the requirements included in the definition of a qualified EHR; and

2.has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary.

HHS. 45 CFR Part 170 Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health

Record Technology; Interim Final Rule. January 13, 2010.

*CCHIT to publish behavioral health

certification criteria this month (July)!!!

Qualified EHR

An electronic record of health-related information on an individual that:

1.Includes patient demographic and clinical health information, such as medical history and problem lists; and

2.Has the capacity to: provide clinical decision support; support physician order entry; capture and query information relevant to health care

quality; andexchange electronic health information with, and integrate

such information from other sources.

HHS. 45 CFR Part 170 Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health

Record Technology; Interim Final Rule. January 13, 2010.

Business Case

Organizational Vision

What do you want to be tomorrow?

Organizational Strategy

How do you “bridge the gap” to tomorrow?

EbHR: The Right “Bridge?” Promises...

Efficiency & Utilization (information management)Quality (decision support, patient education,

interoperability)Performance (standardization)Knowledge (information accessibility)Market share (opportunity, competition)

Expectations...Federal government (HITECH Act)Internal customers (staff)External customers (patients, payers)

Health & Human Services (HHS). Retrieved from healthit.hhs.gov on October 25, 2009.

Journal of American Medical Informatics Association (JAMIA). 2003.

Strategy ResourcesGoalsInitiativesMeasuresManagement

Financial Analysis: Why?

Discounted Cash Flow Valuation…“Valuing an investment by discounting its future

cash flows”(Net Present Value, Cost-Benefit Analysis)

Ross, Westerfield, Jordan. (2006). Fundamentals of Corporate Finance, 7th Edition. McGraw-Hill/Irwin.

Financial Analysis: How?

Cost-Benefit Analysis: Concept

Cash OutCash In

If positive… invest!

If negative…do NOT invest!

Net Present Value = Cash Inflow – Cash Outflow

Benefits

Costs

Cost-Benefit Analysis: Process1. Identify all relevant cash flow measures.

2. Determine appropriate investment time-horizon.

3. Define process for collecting pre-investment (baseline) performance data.

4. Collect pre-investment (baseline) financial performance.

5. Research/Forecast post-investment financial performance per time horizon.

6. Calculate post-investment financial performance benefits & costs.

7. Calculate net present value.

8. Conduct sensitivity analysis to identify influential factors.

Loan Payments

Cash Flows

TIME

CA

SH

FLO

W

REMEMBER…ONLY CASH MATTERS!!! HOW MUCH? WHEN?

(+)

(-)Labor Costs

IMPLEMENTATION POST-IMPLEMENTATION

Time Value of Money…“A dollar today is worth more than a dollar

tomorrow.”INTEREST & INFLATION!!!

Net Present Value & Discounting

Why Use Net Present Value & Discounting?...Time Value of Money

Benefits: Business Revenue Growth

Current Service RevenueNew Service RevenueHITECH Act Reimbursements

Cost-SavingsNumber of StaffServices (e.g. Transcription)Taxation (write-offs,

depreciation) Billing

Coding Time per PatientClaim Processing Time Claim Correction TimeAuditing Data Collection

TimeAuditing Data Analysis Time

Human Resources Payroll Processing Time

Scheduling Pick-Up-to-Hang-Up Time Reminder-Call Time

Reporting Data Collection Time Data Analysis Time Data Submittal Time

Business Intelligence (QI) Data Collection Time Data Analysis Time

Benefits: Clinical Case Management

Case Review Time Discharge & Referrals

Request Generating TimeRequest Processing Time

IntakeBackground Data Collection

Time Insurance Verification Time

Lab OrdersOrder Process TimeError Correction Time

Patient Information Management (chart)

Chart Retrieval Time Charting Time Chart Filing Time

Prescribing Order Generation &

Processing Time Refill Processing Time Error Correction Time

Benefits: A Quick Thought…

How would you apply the increased capacity afforded by EbHR?

1.Reduce staff hours or size?2.Increase patients per clinician?3.Other?

Costs: Hardware Personal computers (desktops, laptops, tablets) Imaging (monitors, printers, scanners) Servers (database, Citrix) Security (high-capacity tape drives)

EHRs: The Complex Problem of Figuring Costs. The Institute for Family Health New York. Referenced from AHRQ (healthit.ahrq.gov) on July 5. 2010.

Costs: Software Licenses (vendor, third party) Server operating system licenses Electronic claims submission Integration (EHR & EPM) Back-up software System/ network monitoring software Integration with general ledger Virus Protection Communication (e.g. MS Office, MS Outlook) Firewall Upgrades

EHRs: The Complex Problem of Figuring Costs. The Institute for Family Health New York. Referenced from AHRQ (healthit.ahrq.gov) on July 5. 2010.

Costs: Property & Infrastructure Furniture (desks, chairs) Office wiring (data, power) Data center (closet, ventilation, power, uninterruptable

power supply, racks) Networking equipment (routers, switches) Wide area connections to remote sites Back-up connections (DSL, Cable) Internet Connections

EHRs: The Complex Problem of Figuring Costs. The Institute for Family Health New York. Referenced from AHRQ (healthit.ahrq.gov) on July 5. 2010.

Costs: Services Customization Training & Re-Training (current, future staff)* User support Maintenance contracts Internal help desk (software supported) Insurance

EHRs: The Complex Problem of Figuring Costs. The Institute for Family Health New York. Referenced from AHRQ (healthit.ahrq.gov) on July 5. 2010.

Costs: Labor, ImplementationDecidingLearningAnalyzingSelecting VendorPlanning & Managing

Time

Imp

lem

en

tat

ion

Lab

or

Costs

Implementation

Post-Implementation

Designing & CustomizingInstalling & TestingTraining, Educating &

SupportingUpgrading & MaintainingCertifying & Improving

Costs: Labor, New Chief Information Officer (CIO) Help desk support EHR/EPM system analyst PC/Desktop support Network Support Database administrator Report programmer

EHRs: The Complex Problem of Figuring Costs. The Institute for Family Health New York. Referenced from AHRQ (healthit.ahrq.gov) on July 5. 2010.

Costs: Loss of Revenue?

Time

Reven

ue

Implementation

Post-Implementation

Decreased Productivity

EHRs: The Complex Problem of Figuring Costs. The Institute for Family Health New York. Referenced from AHRQ (healthit.ahrq.gov) on July 5. 2010.

Cost-Benefit Analysis: Example

Summary Align investment with organizational vision & goals Apply “balanced scorecard” (objective, subjective) for

holistic financial analysis. Budget for decrease productivity during implementation Over-budget staff training.

DOQ-IT Business Case For Quality: What Is Known. Referenced from AHRQ website (healthit.ahrq.gov) on July 5. 2010.

Readiness

What is “Readiness?”

Why is readiness important?

“Help healthcare organizations detect potential obstacles and improve chances of successful implementation

Readiness for Implementation Scale

RIS Metrics

RIS Performance

RIS PerformanceAgencies Scoring 75% of Total Factor Scores

Organizational

Motivation

Meeting Needs &

Usefulness

Awareness &

Support

Departmental Fit

Implementation

Organizational

Environment

Promotion

Level of Influence

22% 18% 18% 14% 11% 11% 6%

Agency A Agency B Agency C Agency D Agency E Agency F Agency G

Organizational MotivationEbHR implementation should:

1.Articulate how implementation fits with organizational and client/patient care goals

2.Help address or solve a key organizational problem3.Consider the implementation business case 4. Create awareness of client benefits5.Understand the level of leadership support6.Examine resource allocation supporting implementation

Meeting Needs & UsefulnessEbHR implementation must:

1. Ease and frequency of technology updates

2. Offer affordability (e.g., Business case)

3. Offer accessibility in the agency for staff using the EbHR

4. Ease of navigations for staff and consumers

5. Provide technical help for users and staff

6. Adapt to the expected use of EbHR by staff

Awareness & SupportEbHR creates implementation awareness and support by:

1. Encouraging key opinion leader perception of and support2. Gaining support of clinical managers or supervisors3. Enhancing key stakeholder understanding and how EbHR will be used4. Helping clinical staff see how implementation will benefit clients5. Allowing clinicians to build client trust in order to promote active use6. Addressing concerns of powerful organizational skeptics who can block

implementation

Departmental FitEstablishing a positive view towards department fit for EbHR implementation by:

1.Working with a well-respected department in the organization

2.Ensuring that implementation will be successful in the selected department

3.Integrating the EbHR into agency workflow (e.g., services and procedures)

4.Anticipating and being prepared for technical difficulties

5.Using adequate training to ensure staff familiarity and acceptance

6.Measuring the effect of EbHR on staff workload

7.Understanding effect of implementation on care provider role and relationships

ImplementationEstablish a positive organizational view about the implementation process by:

1.Incorporating the role of a EbHR within organizational guidelines

2.Ensuring that the EbHR can be customized to meet agency needs

3.Developing a clear process to identify, refer, and support users of the EbHR

4.Providing staff training during implementation

5.Using implementation feedback to remove barriers and improve processes.

Organizational Environment1. Prior history of successful innovation of technology

implementation

2. Leadership innovativeness

3. Internal turbulence (e.g., restructuring, staff turnover, organizational change, etc.)

4. Teamwork and cooperation (1) within departments and (2) across departments

5. Degree to which external influence from the field support EBHR adoption

PromotionDuring EBHR Implementation the organization should

1. Persistently promote EbHR benefits for the organization and for clients

2. Identify an influential administrative champion to promote its benefits

3. Identify an influential clinical champion to promote its benefits

4. Provide regular implementation reports to key stakeholders

Key Success Factors Align technology with organizational goals Understand the customer (staff and clients) Lead change – gain support from champions

(administrators, clinical) Dedicate sufficient resources Choose the “right” teams Select realistic time lines Analyze workflows, benchmark performance Measure cultural support & resistance Market the benefits & challenges “Be” the credible, informed expert Exude ENTHUSIASM!!!