Rural Health IT & ARRA 2009: How to Fund Your HIT Projects President Barack Obama Health IT is Non-Negotiable

Purpose of American Recovery & Reinvestment Act (ARRA 2009) The legislation aims to stimulate the economy through investments in infrastructure, unemployment benefits, transportation, education, healthcare; and includes over $20 billion to aid in the development of a robust IT infrastructure for healthcare and to assist providers and other entities in adopting and using health IT.

HIT Funding from ARRA 2009 Total funding included for health IT is as follows: $2 billion for the Office of the National Coordinator (ONC) $17.2 billion in incentives through the Medicare and Medicaid reimbursement systems to assist providers in adopting EHRs $1.1 billion for comparative effectiveness research within the Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health (NIH), and the Department of Health and Human Services (HHS). $85 million for health IT, including tele-health services, within the Indian Health Service $1.5 billion for construction, renovation, and equipment for health centers through the Health Resources and Services Administration $500 million for the Social Security Administration $50 million for information technology within the Veterans Benefits Administration $2.5 billion for the U.S. Department of Agricultures Distance Learning, Telemedicine, and Broadband Program $4.7 billion for the National Telecommunications and Information Administrations Broadband Technology Opportunities Program

ARRA 2009 and its Effect on HIT This changes everything: HITs $20 Billion represents nearly 3% of the total stimulus package Relative to the size of the HIT industry this is a mind-boggling figure: – HIT is estimated to be $19B - $50B / yr sector (variance due to definitional and measurement differences). – Thus the $20B figure is equal to, by some measures, the total size of the industry! Has any other sector, relative to its size, received this degree of economic stimulus funding?

Rural Health IT Corporation (RHITC) Experience Writing and Managing Award Winning HIT/EMR Grants Health Information Exchanges Interoperable IT Solutions Disease Management Programs Project Management, chiefly, merging clinical workflow with new technology tools in addition to staff preparation and education

RHITC Award Winning HIT Grants AHRQ 1P20 HS (PI Lord) 10/01/04-09/30/05 Transforming Healthcare Quality through Information Technology for the Critical Access Hospital Consortium NH/VT $200,000 award AHRQ 1 UC1 HS (PI Sims) 10/01/ /30/08 Improving Rural Healthcare: Implementing Innovative Integration Solutions for the Critical Access Hospital Consortium including Dartmouth Hitchcock Medical Center $970,000 award HRSA Health Information Exchange (HIE) with Univ. of North Dakota, three CAHs and tertiary center (Ref: HRSA FLEX CAH HIT Implementation Grant No.H54RH08680 (PI Miller) ( – ) $1,600,000 award HRSA Grant No. D06RH for HRSA CAH HIE Network Development project at Transylvania Community Hospital Brevard, NC and seven clinics (PI Lord) ( – ) $540,000 award

Current HIT Grant Opportunities & RHITC Experience html AHRQ: Utilizing Healthcare Technology to Improve Healthcare Quality html html NIH: Using HIT to Improve Substance Abuse Treatment html ceReentrySol.pdf USDoJ Second Chance Act ceReentrySol.pdf

RHITC Grant Services Identify Grant/Earmark Opportunities Identify applicable opportunities and value details of the Grant Review Grant Requirements Review Scoping and Requirements Gathering of the Proposed EMR/technology Requirements Gathering of Necessary Answers to Grant Application Questions Development of specific Grant Application requirements Development of an Implementation Narrative Development of a Work Plan Development of an Evaluation Plan Review Final Grant Application Finalize and submit Application to Grant Agency Coordinate Congressional and local government support Maintain continuing communications with Grant Administrators and USDA/HRSA/HHS/AHRQ/NIH/OAT, SAMSHA, USDOJ Jointly develop clinical workflow protocols Jointly develop and enhance the EMR system Jointly develop EMR merger with clinical workflow protocols Jointly develop provider staff/user education & training of a new EMR/EHR Introduce, coordinate, and develop relationships with government agencies & HIT organizations Develop RHITC Disease Management protocols

RHITC CDM & Health Quality Improvement Services RHITC has developed CDM protocols that align with current federal and state legislative and regulatory efforts to increase quality through greater outcomes-data transparency and accountability. Example: PQRI Quality Reporting Initiatives need to be coordinated with parallel public efforts around Healthcare Information, the adoption of Electronic Health Record Systems, and the establishment of Health Information Exchanges capable of sharing the needed information. Information Technology can be leveraged to drive better healthcare choices as well as quality, value, and efficiency through the system. By assisting with the Quality Improvement movement and the national framework for Healthcare IT, RHITC believes it can help create a more information-rich, consumer-centric system, and better healthcare for all.

Patient-Centered Medical Home National Committee for Quality Assurance(NCQA) has partnered with the American College of Physicians (ACP), American Academy of Family Physicians(AAFP), American Academy of Pediatrics (AAP) and American Osteopathic Association (AOA) to propose a new model for delivering primary care services. Some pilot testing is underway to increase substantially reimbursements to physicians whose practices comply with PCMH guidelines. Requirements of the Patient: Patient-Centered Medical Home Access and Communication Patient Tracking and Registry Functions Care Management Patient Self SelfManagement Support Electronic Prescribing Test Tracking Referral Tracking Performance Reporting and Improvement Advanced Electronic Communications

P4P & Quality Initiatives: A New Practice Model Most HMO plans have P4P programs Managed Medicaid & Medicare plans have P4P programs CMS experimenting MCMP (Medicare Care Management Program) PQRI (Physician Quality Recognition Initiative) Most programs focus on NCQA HEDIS type quality measures Several programs now include monies to encourage the implementation and use of Health Information Technology Recognition of HIT as a means of achieving quality results and improve reporting mechanisms Recognition of most benefits of implementing HIT do not accrue to the physician who has the cost burden

P4P & Quality Initiatives: BCBS P4P Programs Disease Management Diabetes Management Combined measure: HBA1C+microalbumin+LDL Eye exams Lipid management for CAD, CHF Asthma management Preventive Health Care Colorectal cancer screening Breast cancer screening w/mammography BMI screening Generic Prescribing

P4P & Quality Initiatives: Medicare P4P Programs Medicare Care Management Performance (MCMP) demonstration) In 2007, CMS enrolled small practices in AK, CA, MA & UT to evaluate a Medicare P4P process that gives incentives for quality care as well as additional incentives for reporting quality data in an electronic format A number of clinics are participating in the program which is worth up to $12,500 per physician per year for 3 years, depending on performance and reporting In fall 2007, baselines were reported to CMS Presently, all clinics are working in teams to improve care in the areas needed to achieve success in the demonstration

Evidence P4P, Transparency, & Quality Initiatives Work Major improvements in quality and costs. In just two years since the last survey in 2006, the percentage of programs that report improvements in quality due to P4P almost doubled reported IHA, the Leap Frog Group, and Med-Vantage. Now more than half of P4P programs cite measureable increases in their providers clinical quality, the area that has been part of P4P the longest. Other areas with major jumps in P4P effectiveness were patient survey results, cost control and especially adoption of IT tools. Tom Williams, Executive Director of Integrated Healthcare Association of CA (IHA) said, These data show that P4P has helped dispel the once strongly held belief that we could not measure quality in healthcare. We now see P4P being used in multiple settings to measure and improve the quality of care, cost efficiency and use of technology. All of health care today is under pressure to produce better valuebetter quality for the cost expended. P4P is helping build a culture of accountably, improvement and incentives to achieve this objective.

EMR READINESS

Getting Started The success of any major technology initiative weighs heavily on three organization factors: People, Process and Technology. Often times, organizations look to the technology itself as the core solution, neglecting the human and workflow impact on the overall organization

Preparing People & Process People: Process: Technology: – Assess current state of user adaptation to technology – Example: Below Average 16% Average 50% Above Average 34% – Assess current environment: clinical workflow, processes, and practices to determine state of EMR/EHR preparedness

Preparedness Strategies People Identify the status of your workforce Train on basic computer skills (requirement) Process and Workflow Review Assess current workflow – Look for redundancies in processes across departments, shifts, and floors – Look for duplication and inconsistencies in manual processes – Gather complaints in process, suggestions for process improvements – Identify issues in the process

Preparing Strategic Plan People and Process Understand current state of people and process – Determine the gaps and develop a plan Develop training and education programs Determine and Implement Best Practices Identify and correct workflow issues Identify and reduce redundancies of processes Develop a strategic plan… …A strategic plan must be determined by a combination of this data, goals, funding, staff, workflow, experience, initiatives and future planning…

Elements of the Strategic Plan Develop an IT Strategic Roadmap encompassing: – A clearly defined roadmap that is consistent with the strategic/business plan – Build an IT steering committee consisting of multiple departments decision makers – Have a physician and clinical champion – Set forth processes for implementing any new systems, solutions or technology enhancements: All new system considerations go through a review and evaluation process by the committee – Check for compatibility, standardizations(HL7) and interoperability – Does it map to the business strategies and goals

Benefits of an EMR a. Standardized organization of the chart. b. Legibility. c. Access to the record by all staff who need it from any location either in the facility or elsewhere given computer access and appropriate permissions. d. Improve communication among the members of the care team. e. Improved medication record keeping and improved safety for residents by reducing the risk of medication errors. f. Decrease in duplicate, redundant or unnecessary care with improved documentation. g. Improved documentation by caregivers resulting in more accurate and complete representation of care given. h. Improved capture of care given and improved charge capture from the record. i. Facilitation of information gathering and extraction from the record to document outcomes and assist with quality improvement. j. Allow residents to access health information and participate more fully in their care. k. Improved efficiency with data entry, abolishing the need for redundant entry of data into different systems.

HIT/EMR Action Plan Complete EMR Readiness Assessments Develop business/sustainability plan & goals Identify staff experience & skills through survey, interviews, & comments Review Infrastructure strengths & weaknesses, including HIPAA, other regulations, security & privacy Legacy system preferences Vendor preferences including integration experience Develop clinical champions Obtain funding Learn from others successes Finalize planning Begin EHR Development

RHITC Contact Earle Rugg, CEO 1950 Lafayette Road, Suite 207, Box 1 Portsmouth, NH