SAAS National Conference & NIATx Summit

1. 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

2. ‘‘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

3. Objective To position you for guiding electronic behavioral health records (EbHR) implementation by: • Learning how EbHR aligns with your organization; • Learning how EbHR impacts your organization; • Learning how EbHR was implemented by others; and • Developing your EbHR message & plan.

4. Agenda 8:30am – 8:45am Introduction 8:45am – 10:15am Basics: Terminology, Business Case, Readiness 10:15am – 10:30am Break (206) 10:30am – 12:00pm Impact: Trust & Relationships 12:00pm – 1:00pm Lunch (206) 1:00pm – 2:30pm How: Learning from Experts 2:30pm – 2:45pm Break (206) 2:45pm – 4:15pm Taking Action: Developing Your Message & Plan 4:15pm – 4:30pm Wrap-up

5. Your Presenters • Dr. Jay Ford • NIATx, Director of Research • PhD Industrial Engineering • Director of Research • jay.ford@chess.wisc.edu • Matt M. McCluskey • EHR & Process Improvement Consultant • MS Healthcare Systems Engineering, MBA General Business, Leadership, Strategy • mmmccluskey@gmail.com

6. Our Audience • Your name & job title • Your employer name & location • Your experience & knowledge (EbHR)

7. 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

8. 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.

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

10. Electronic Health Records (EHR) An electronic record of health-related information on an individual that: • conforms to nationally recognized interoperability standards and • can be created, managed, and consulted by authorized clinicians and staff across more than onehealth care organization. Health Information Exchange… The sharing of clinical and administrative data across the boundaries of health care institutions, health data repositories, and States. 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.

11. Electronic Behavioral Health Records (EbHR) An electronic record of behavioralhealth-related information on an individual that: • conforms to nationally recognized interoperability standards and • can be created, managed, and consulted by authorized clinicians and staff across more than onehealth care organization.

12. 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.

13. 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.

14. Federal Policy

15. Federal Policy • Background (HITECH Act) • Leadership (ONC) & Resources • Incentive Programs • Medicare & Medicaid (H.R. 5040) • Meaningful Use • Certified technology

16. Background • American Recovery & Reinvestment Act (ARRA) of 2009 (Recovery Act) • Obama signed into law February 17, 2009 • Health Information Technology for Economic & Clinical Health (HITECH) Act • ARRA Div. A Title XIII & Div. B Title IV • Authorizes 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.

17. 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 HIT • Train personnel in the use of HIT • Improve the secure HIE among providers (including primary care) • Improve HIT for adaptation to community-based behavioral health settings • Assist with the implementation of telemedicine • Collaborate and integrate with HIT regional extension centers The Library of Congress (THOMAS). thomas.loc.gov. July 5, 2010.

18. 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

19. Incentive Programs: Medicare • Medicare Fee-for-Service & Medicare Advantage EHR Incentive Program • Eligibility • Professionals (EP), Hospitals, Critical Access Hospital (CAH) • Doctors of medicine or osteopathy • Doctors of dental surgery or dental medicine • Doctors of podiatric medicine • Doctors of optometry • Chiropractors • Payment • EP: $44,000 per physician (max) between 2011 and 2016 • Hospitals: Medicare share, initial amount, other • Penalty • Medicare fee schedule incremental reduction (1% - 5%) after 2015 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.

20. Incentive Programs: Medicaid • Medicaid EHR Incentive Program • Eligibility • FQHC & RHC Professionals (EP), Children’s & Acute Care Hospitals • Physicians • Dentists • Certified nurse-midwives • Nurse practitioners • Physician assistants • Payment • EP: $63,750 per physician (max) over 6 years • Hospitals: EHR total cost, Medicaid share • Penalty • Not 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.

21. Meaningful Use An 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: • Demonstrates use of certified EHR technology in a meaningful manner; • 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 • 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.

22. Certified EHR A complete EHR or a combination of modules, each of which: • meets the requirements included in the definition of a qualified EHR; and • 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. *CCHIT to publish behavioral health certification criteria this month (July)!!! 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.

23. Qualified EHR An electronic record of health-related information on an individual that: • Includes patient demographic and clinical health information, such as medical history and problem lists; and • Has the capacity to: • provide clinical decision support; • support physician order entry; • capture and query information relevant to health care quality; and • exchange 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.

24. Business Case

25. Organizational Vision What do you want to be tomorrow?

26. Organizational Strategy How do you “bridge the gap” to tomorrow?

27. 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.

28. Strategy Resources • Goals • Initiatives • Measures • Management

29. Financial Analysis: Why?

30. Financial Analysis: How? 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.

31. Cost-Benefit Analysis: Concept Net Present Value = Cash Inflow – Cash Outflow If positive… invest! Benefits Cash In Cash Out Costs If negative… do NOT invest!

32. Cost-Benefit Analysis: Process • Identify all relevant cash flow measures. • Determine appropriate investment time-horizon. • Define process for collecting pre-investment (baseline) performance data. • Collect pre-investment (baseline) financial performance. • Research/Forecast post-investment financial performance per time horizon. • Calculate post-investment financial performance benefits & costs. • Calculate net present value. • Conduct sensitivity analysis to identify influential factors.

33. Cash Flows (+) POST-IMPLEMENTATION IMPLEMENTATION Revenue Growth Cost-Savings CASH FLOW TIME Loan Payments Labor Costs (-) Revenue Loss REMEMBER… ONLY CASH MATTERS!!! HOW MUCH? WHEN?

34. Net Present Value & Discounting Time Value of Money… “A dollar today is worth more than a dollar tomorrow.” INTEREST & INFLATION!!! Why Use Net Present Value & Discounting?... Time Value of Money

35. Benefits: Business • Revenue Growth • Current Service Revenue • New Service Revenue • HITECH Act Reimbursements • Cost-Savings • Number of Staff • Services (e.g. Transcription) • Taxation (write-offs, depreciation) • Billing • Coding Time per Patient • Claim Processing Time • Claim Correction Time • Auditing Data Collection Time • Auditing 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

36. Benefits: Clinical • Case Management • Case Review Time • Discharge & Referrals • Request Generating Time • Request Processing Time • Intake • Background Data Collection Time • Insurance Verification Time • Lab Orders • Order Process Time • Error 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

37. Benefits: A Quick Thought… How would you apply the increased capacity afforded by EbHR? Reduce staff hours or size? Increase patients per clinician? Other?

38. 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.

39. 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.

40. 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.

41. 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.

42. Costs: Labor, Implementation • Deciding • Learning • Analyzing • Selecting Vendor • Planning & Managing • Designing & Customizing • Installing & Testing • Training, Educating & Supporting • Upgrading & Maintaining • Certifying & Improving Implementation Post-Implementation Implementation Labor Costs Time

43. 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.

44. Costs: Loss of Revenue? Implementation Post-Implementation Decreased Productivity Revenue Time EHRs: The Complex Problem of Figuring Costs. The Institute for Family Health New York. Referenced from AHRQ (healthit.ahrq.gov) on July 5. 2010.

45. Cost-Benefit Analysis: Example

46. 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.

47. Readiness

48. What is “Readiness?”

49. Why is readiness important? “Help healthcare organizations detect potential obstacles and improve chances of successful implementation

50. Readiness for Implementation Scale