Implementation of an Implementation of an Electronic Health RecordElectronic Health Record

Mark Ficker Mark Ficker Vice President, Medical Group Services & Chief Vice President, Medical Group Services & Chief Financial OfficerFinancial Officer

Brown & Toland OverviewBrown & Toland Overview

MissionMission

Brown & Toland Medical Group is a leading

organization of community and academic

physicians. We are committed to providing

superior, coordinated and comprehensive medical

services.

Owned and governed by physicians, we provide

excellent healthcare, product choice, and value to

our patients through clinical integration,

innovation, and technology.

Leading organization of community and academic physicians

Community Physician

Owned and governed by physicians

Brown & Toland Medical GroupBrown & Toland Medical Group

IPA with 195,000 MembersIPA with 195,000 Members

1,500 Physicians1,500 Physicians

Product Offerings & ServicesProduct Offerings & Services

Financial HealthFinancial Health

Northern California Health Care Northern California Health Care MarketplaceMarketplace

Key Business ObjectivesKey Business Objectives

• Develop disease management programs

• Develop an outcomes measurement program

• Improving health in the community

• Recognize, reward & assist high quality, efficient, & effective physician practices

• Improve physician office staff education programs

- Physician Office Services

- Network Management

- Product Development

- Information Technology

- Human Resources- RX Management

- Claims administration & eligibility

- Customer service- Care management- Quality

improvement- Finance- Data Warehouse &

DSS

Enhance Clinical Integration: Continue to develop processes and systems to clinically integrate care across the BTMG physician network.

Health Improvement and Quality Improvement: Continue to promote clinically integrated, comprehensive patient health care through health improvement and quality improvement programs.

Organizational Cost Reductions: Reduce organizational cost through improving the quality of patient care delivered and by continuing to implement administrative efficiencies.

Network Diversification and Product Administration: Provide a comprehensive, cost effective, high quality network of health care and administrative services for all competitive medical benefit plan models.

Physician Services: Provide administrative and point of care services that will efficiently manage the physician’s practice and enhance the overall quality of care provided.

Regulatory Compliance: Continue to comply with all regulatory requirements.

Building a Strong FoundationBuilding a Strong Foundation

Brown & Toland Brown & Toland Medical Group CharacteristicsMedical Group Characteristics

Patient centric Accessible services Patient & MD is known to system Care & care management is coordinated across the continuum Clinical & administrative data is accessible enterprise-wide Consolidated financial processes Enterprise-wide reporting with “feedback loops” Support for wellness and knowledge transfer to patient

Ancillary ServicesAncillary Services

• Lab• Radiology• Pharmacy• PT

AdministrationAdministration

• Eligibility Management• Care Management• Claims processing• Capitation management• General financials• Decision support

PatientAdvocacy

PatientAdvocacy

• Customer service• PCP assignment• Demand management• Credentialing

Patient AccessPatient Access

• Scheduling Online• Nurse advice• Physician access• eOffice Visits• Rx Renewals

Medical DeliveryMedical Delivery

• Primary care • Specialty consulting • Acute• Post acuteResearch &

EducationResearch & Education

Population ManagementPopulation

Management

• Outcomes• Best practices• Research

• Protocols• Pathways• Medical policies• Practice guidelines• Clinical decision support• Alerts & Reminders• Journals

Medical Knowledge

Medical Knowledge

PatientIntervention

PatientIntervention

• Case management• Concurrent review• Wellness management• Preventive management• Disease management

• Internet• Member view of clinical record• Personal disease management• Self help • General Health Information

Patient Education

Patient Education

Core Medical Group Characteristics

Staged IT Strategy: 2000 - 2008Staged IT Strategy: 2000 - 2008

•IDX Optimization & Data Quality•RACER Replacement•Data Warehouse/Data Marts•InterQual Implementation•Web Foundations•Portal Development & eArchitecture•HIPAA Risk Assessment•Disaster Recovery Planning•Help Desk

• HIPAA Remediation

• Web EMR Options Analysis & System Selection

• Clinical Protocols & Alerts• Physician/Patient Connectivity• Decision Support Reporting• Medical/Disease Management

Programs• Evaluate CRM Options• Expanded Network Services• End User Device Standards• Remote Access Control• Operational Improvements

• Physician Services – Integrated PMS & EMR

• All Product Offering

• Sustainability and Competitive Advantage

2004 - 20082004 - 20082000 - 2003

DifferentiateDifferentiate TransformatioTransformationn

Operational EfficiencyOperational Efficiency & Regulatory Risk & Regulatory Risk

AssessmentAssessment

$8 Million $10 - 12 Million

Clear and Sound Corporate Strategic Direction

Business Unit-wide Synchronization of BusinessPlans, Processes and Systems

Senior Management Support, Joint-Ownership,and Communication of IT Strategic Vision and Plans

Appropriate IT Leadership, Skills, and Staffing Levels

Durable Infrastructure and Sound Standards

SystemsIntegration & Control

Applications

UserBenefits

User focus is typically at the “surface” & on their own expected benefits

How well systems provide these benefits depends upon a solid,

“below the surface” foundation

Reliable Information Management

Shared IT Vision and Road Map

Appropriate Context

and Confidence

Foundation for IT SuccessFoundation for IT SuccessIT success depends on establishing a solid foundation to enable IT success depends on establishing a solid foundation to enable

strategies and deliver expected outcomes & benefitsstrategies and deliver expected outcomes & benefits

Physician Practice Solutions Physician Practice Solutions StrategyStrategy

Business Needs Business Needs

Operational RealityOperational Reality

Enhanced Business

Performance

IncreasedCollections

ImprovedPatient

Satisfaction

ReducedExpenses

Daily operations are not allowing physiciansto focus all their attention on what they do best

Treating patients

Studies have shown that up to 70% of potential business performance improvements are driven by changes to organizational workflow on the "front

end," or patient access component, of the revenue cycle.

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Goals of the ServicesGoals of the Services

Information AboutInformation AboutPatientsPatients

Information AboutInformation AboutCareCare

““Nothing will ever be attempted if Nothing will ever be attempted if all possible objections must all possible objections must

first be overcome.”first be overcome.”Samuel Johnson

The Brown & Toland ViewThe Brown & Toland View

Provide Greater Efficiency to Provide Greater Efficiency to Physician GroupsPhysician Groups

Patient Eligibility & Patient Eligibility & Benefit Plan VerificationBenefit Plan Verification

Direct Claims Submission Direct Claims Submission & Contract Rate & Contract Rate VerificationVerification

Reconcile Patient Reconcile Patient Schedule with Charge Schedule with Charge CaptureCapture

Increase Coding Increase Coding AccuracyAccuracy

Increase turnaround time Increase turnaround time for authorizations and for authorizations and Referrals - Rules Referrals - Rules IntegratedIntegrated

Decrease Charting Time Decrease Charting Time & Eliminate Dictation & Eliminate Dictation CostCost

Reduce Office LaborReduce Office Labor

Decrease Record Decrease Record StorageStorage

Network Efficiency & Cost Network Efficiency & Cost SavingsSavings

Patient Information Available at the Point of CarePatient Information Available at the Point of Care

Network Diagnostic Results Reporting & Shared Data Network Diagnostic Results Reporting & Shared Data between Primary Care & Specialty Carebetween Primary Care & Specialty Care

Eliminate Unnecessary Duplication of Diagnostic TestingEliminate Unnecessary Duplication of Diagnostic Testing

Increase Efficiency of Referrals and AuthorizationsIncrease Efficiency of Referrals and Authorizations

Improve Patient & Physician SatisfactionImprove Patient & Physician Satisfaction

Reduce Medical Errors Reduce Medical Errors

The Physician’s InputThe Physician’s Input

Focus Group Discussions and Interview Focus Group Discussions and Interview ResultsResults

Interview ThemesInterview Themes Large demand for billing services – this will be a “quick win” with the Large demand for billing services – this will be a “quick win” with the

physiciansphysicians

Critical to articulate the ‘preferred cost structure’ and specific benefits to Critical to articulate the ‘preferred cost structure’ and specific benefits to be gained by optioning BTMG’s servicesbe gained by optioning BTMG’s services

EMR is essential to recruit younger physicians but will be resisted by older EMR is essential to recruit younger physicians but will be resisted by older physician population that is less computer savvyphysician population that is less computer savvy

Will need ability to deploy EMR modularly due to variances in adoption Will need ability to deploy EMR modularly due to variances in adoption and practice preferencesand practice preferences

Contract with EMR vendor will need to be “staged” for growthContract with EMR vendor will need to be “staged” for growth

EMR will support P4P reimbursement criteriaEMR will support P4P reimbursement criteria

Reliability is key – a lot of dissatisfaction with current systems and vendor Reliability is key – a lot of dissatisfaction with current systems and vendor supportsupport

Inefficiencies are prevalent in practicesInefficiencies are prevalent in practices

Interview ThemesInterview Themes Common systems (especially PPMS) is a huge benefit – can Common systems (especially PPMS) is a huge benefit – can

draw from a larger pool of experienced staffdraw from a larger pool of experienced staff Several practices are ‘already looking for new systems’Several practices are ‘already looking for new systems’ New systems must be ‘physician friendly’ and easy to deployNew systems must be ‘physician friendly’ and easy to deploy Physicians will need to overcome residual mistrust of BTMG Physicians will need to overcome residual mistrust of BTMG

from previous de-install of PPMSfrom previous de-install of PPMS System needs to be ‘underwritten’ by BTMG (hardware, System needs to be ‘underwritten’ by BTMG (hardware,

software, communications)software, communications) Must be a ‘good deal’ (less cost and more efficient) and a it Must be a ‘good deal’ (less cost and more efficient) and a it

imperative that the benefits are clearly articulated for buy-inimperative that the benefits are clearly articulated for buy-in Data conversions from existing PPM systems will be neededData conversions from existing PPM systems will be needed Resistance to EMR from older physicians expectedResistance to EMR from older physicians expected Resistance to PPMS from entrenched billing managers expectedResistance to PPMS from entrenched billing managers expected

Key Functional PrioritiesKey Functional PrioritiesBased on the stakeholder interviews the following key functional priorities emerged:

EDI billingEDI billing Contractual variancesContractual variances Insurance follow-upInsurance follow-up Tracking status of paymentsTracking status of payments Effective date for co-payEffective date for co-pay ““Bubble forms” for charge captureBubble forms” for charge capture

Flexible scheduling featuresFlexible scheduling features Scanners for insurance cardsScanners for insurance cards

Results reportingResults reporting Workflow (refills)Workflow (refills) ePrescribing w/formularyePrescribing w/formulary Ease of charge captureEase of charge capture Note entryNote entry Voice recognitionVoice recognition Disease managementDisease management

Billing & ReportingBilling & Reporting

SchedulingScheduling

Electronic Medical Record

Electronic Medical Record

Drug interactions Health maintenance Problem lists HEDIS measures Guidelines Clinical reporting , e.g. lipid values

Flexible A/R reporting Collections module Multiple payor types/PPO products Contact capitation Using claims data for clinical research

and assist with disease mgmt

Link with prior authorization

Physician Practice Solutions Physician Practice Solutions StrategyStrategy

System SelectionSystem Selection

Brown & Toland Brown & Toland Medical Group CharacteristicsMedical Group Characteristics

Patient centric Accessible services Patient & MD is known to system Care & care management is coordinated across the continuum Clinical & administrative data is accessible enterprise-wide Consolidated financial processes Enterprise-wide reporting with “feedback loops” Support for wellness and knowledge transfer to patient

Ancillary ServicesAncillary Services

• Lab• Radiology• Pharmacy• PT

AdministrationAdministration

• Eligibility Management• Care Management• Claims processing• Capitation management• General financials• Decision support

PatientAdvocacy

PatientAdvocacy

• Customer service• PCP assignment• Demand management• Credentialing

Patient AccessPatient Access

• Scheduling Online• Nurse advice• Physician access• eOffice Visits• Rx Renewals

Medical DeliveryMedical Delivery

• Primary care • Specialty consulting • Acute• Post acuteResearch &

EducationResearch & Education

Population ManagementPopulation

Management

• Outcomes• Best practices• Research

• Protocols• Pathways• Medical policies• Practice guidelines• Clinical decision support• Alerts & Reminders• Journals

Medical Knowledge

Medical Knowledge

PatientIntervention

PatientIntervention

• Case management• Concurrent review• Wellness management• Preventive management• Disease management

• Internet• Member view of clinical record• Personal disease management• Self help • General Health Information

Patient Education

Patient Education

Core Medical Group Characteristics

Vendor Evaluation ProcessVendor Evaluation Process

Core Core Core CorePart Part

Key

Part = Participants

Core = Core Team

= Client

= Narrowing Points

Approvals

Core

Manage Expectations and Vendor CommunicationsManage Expectations and Vendor Communications

ProjectInitiation& Kick-off

ProjectInitiation& Kick-off

ConductVendor

Workshop

ConductVendor

Workshop

DevelopDemo

Scenarios & Scoring

Methodology

DevelopDemo

Scenarios & Scoring

Methodology

Finalizationand

Distributionof the RFP

Finalizationand

Distributionof the RFP

Evaluate RFP Responses &

Determine Leading Vendors

Evaluate RFP Responses &

Determine Leading Vendors

Detail Vendor

Demos & Determine

VendorFinalist(s)

Detail Vendor

Demos & Determine

VendorFinalist(s)

Conduct Finalist(s)

Due Diligence(Site Visit/Ref.Calls)

Conduct Finalist(s)

Due Diligence(Site Visit/Ref.Calls)

Vendor ofChoice

Recommend-ations

Vendor ofChoice

Recommend-ations

BeginContract

Negotiations

BeginContract

Negotiations

DevelopImplementation

Plan

DevelopImplementation

Plan

Develop &Analyze

Requirements

Develop &Analyze

Requirements

BTMG Guiding PrinciplesBTMG Guiding Principles

Focus AreaFocus Area Guiding PrincipleGuiding PrincipleRiskRisk Good reputation for solid vendor supportGood reputation for solid vendor support

State-of-the art software and forward-thinking companyState-of-the art software and forward-thinking company

Stable company with solid track recordStable company with solid track record

TechnologyTechnology Meets database platform standardsMeets database platform standards

Common (single) database between systems (PPMS/MCA/EMR)Common (single) database between systems (PPMS/MCA/EMR)

Enterprise master patient identification (EMPI) abilityEnterprise master patient identification (EMPI) ability

Lower cost of ownership supported through a browser-based Lower cost of ownership supported through a browser-based front endfront end

Implementation/ Implementation/ SupportSupport

Minimize information technology infrastructure at individual Minimize information technology infrastructure at individual physician officesphysician offices

Vendor independence through availability of client-based tools Vendor independence through availability of client-based tools for customizationfor customization

Leverage internal IDX knowledgeLeverage internal IDX knowledge

Ability to deploy EMR in modular manner to accommodate Ability to deploy EMR in modular manner to accommodate variability of use amongst practicesvariability of use amongst practices

Based on the stakeholder interviews the following guiding principles emerged:

Technology & Vendor OptionsTechnology & Vendor OptionsA:A: Single Vendor SolutionSingle Vendor Solution

PPMS/MCA/EMRPPMS/MCA/EMRSingle patient-centric databaseSingle patient-centric database

B: B: Hybrid Solution – multiple vendorsHybrid Solution – multiple vendorsIDX MCAIDX MCA

Interfaced to PPMS/EMRInterfaced to PPMS/EMROther VendorOther Vendor

PPMS/EMRPPMS/EMRSingle patient-centric databaseSingle patient-centric database

C: C: Hybrid Solution – aligned vendorsHybrid Solution – aligned vendorsIDX PPMS/MCAIDX PPMS/MCA

Single patient-centric database Single patient-centric database Allscripts EMRAllscripts EMR

Interfaced to PPMSInterfaced to PPMS

TECHNOLOGY FOUNDATIONTECHNOLOGY FOUNDATIONDelivers operational benefits across the organizationDelivers operational benefits across the organization

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FinancialsEMRAccess

Management

Brown & Toland SolutionBrown & Toland Solution

• Master Patient Index

•Scheduling

•Visit Management

•Eligibility Verification

•Referrals

•Authorization

•Self-Service Web Portals

•Advance Benefit Notice

•Ambulatory Payment Classification

• A Single Financial Solution

•Claims Editing Software

•Combined business Services

•Risk management

•Charge Capture

•Clinical Results

•E-prescribing

•Scan

•Order

•Dictate

•Transcribe

•Document

•Workflow

BTMG will also provide sophisticated reporting systems for physician use

Physician Practice Solutions Physician Practice Solutions StrategyStrategy

Implementation OverviewImplementation Overview

Implementation ImperativesImplementation Imperatives

Solidify Early AdoptersSolidify Early Adopters

Flexible Critical PathFlexible Critical Path

Resource ManagementResource Management

Enterprise AlignmentEnterprise Alignment

Sharing InformationSharing InformationA Major DecisionA Major Decision

EnterpriseEnterprise ModelModel

Clinical Results ReportingClinical Results Reporting

November 1, 2004 Go LiveNovember 1, 2004 Go LiveLabCorpLabCorp

320 of 700 Physician Agreements in place320 of 700 Physician Agreements in placeNext StepsNext Steps

Additional Training Sessions – increase Additional Training Sessions – increase adoptionadoptionAdditional Lab VendorsAdditional Lab VendorsRadiology ResultsRadiology Results

Clinical Results Reporting – Clinical Results Reporting – Lessons LearnedLessons Learned

1 Physician : 2-3 Staff1 Physician : 2-3 Staff

Flexible Training Timetable & ApproachFlexible Training Timetable & Approach

HIPAA Privacy RegulationsHIPAA Privacy RegulationsLab VendorsLab Vendors

Physician OfficesPhysician Offices

Building Trust & Buy InBuilding Trust & Buy In

Full EMR AdoptionFull EMR Adoption

Focused on early adoptersFocused on early adoptersSlow ramp upSlow ramp up

25 Physicians by end of 2005 25 Physicians by end of 2005

Build to core group over 2-3 year periodBuild to core group over 2-3 year periodUse experience and success of early Use experience and success of early adopters to move late adoptersadopters to move late adopters

Full EMR Adoption – Lessons Full EMR Adoption – Lessons LearnedLearned

Demand greater than expectedDemand greater than expectedLarger groups appear to be early adopters Larger groups appear to be early adopters although more interest than expected from solo although more interest than expected from solo practitionerspractitionersInvestment in experienced and focused Investment in experienced and focused deployment team has been invaluable in working deployment team has been invaluable in working through implementation issues and process through implementation issues and process changeschangesModular approach will facilitate adoptionModular approach will facilitate adoptionPhysician champion in each officePhysician champion in each office

Physician Practice Solutions Physician Practice Solutions StrategyStrategy

In SummaryIn Summary

Physicians have not invested heavily in technology Physicians have not recognized ROI with existing systems Physicians have not had solid, coordinated IT Support Improve practice’s financial health through improved billing and

reimbursements Strengthen ability to provide high quality care through the use of

solid IT systems

BTMG’s IT Strategy Supports BTMG’s IT Strategy Supports Key Business DriversKey Business Drivers

“Known” to BTMG throughout the enterprise

Improve quality of care through patient-centric view of health record Need to recruit younger physicians

Strengthen medical management Manage costs of care delivery through

improved access to clinical data and use of best practices

Recognize revenues from P4P through technology deployment

Expand services to better meet business needs of BTMG physicians

Patient

Physician Physician Services Services StrategyStrategy

PPMSPPMSEMREMR BTMG

Physicians

Three-Step ApproachThree-Step Approach

Due DiligenceDue Diligence IDX / Allscripts to provide IDX / Allscripts to provide

BTMG with formal BTMG with formal proposals:proposals:

To support proposed To support proposed modules & modules & implementation implementation approach & timingapproach & timing

Detail bid based on Detail bid based on specific sizing & specific sizing & staging of roll-outstaging of roll-out

Conduct several Conduct several reference calls to reference calls to comparable vendor comparable vendor clients to discuss clients to discuss support, training, support, training, implementation and implementation and overall satisfaction.overall satisfaction.

Implementation Implementation Planning & Planning & ContractingContracting

Develop overall cost of Develop overall cost of ownership and revenue ownership and revenue model for software and model for software and servicesservices

Refine implementation Refine implementation approach and roll-out approach and roll-out plansplans

Determine key Determine key negotiating points and negotiating points and strategystrategy

Conduct negotiationsConduct negotiations

Activities to Occur in Parallel

Focus GroupsFocus Groups Establish functional & Establish functional &

technical focus groups to technical focus groups to perform detail due perform detail due diligencediligence

Provide education on the Provide education on the features/functions offered features/functions offered with PPMS & EMRswith PPMS & EMRs

Conduct survey to Conduct survey to determine key drivers for determine key drivers for physiciansphysicians

Define key functional Define key functional requirements and requirements and technical environmenttechnical environment

Define specific benefits to Define specific benefits to be achieved with the new be achieved with the new software and BTMG’s software and BTMG’s servicesservices

Minimize RisksMinimize RisksSetting expectations is criticalSetting expectations is critical

BTMG offering “will need to be better and cheaper than what I BTMG offering “will need to be better and cheaper than what I have today”have today”

Ownership of “data” (especially clinical data) may present Ownership of “data” (especially clinical data) may present concerns over loosing control of their practicesconcerns over loosing control of their practices

EMR AdoptionEMR Adoption

Older physician population may not embrace new clinical Older physician population may not embrace new clinical technologiestechnologies

Contracting for “best price” but unknown participation will be a Contracting for “best price” but unknown participation will be a challengechallenge

Clear requirement for modular implementation to address Clear requirement for modular implementation to address various levels of interest various levels of interest

Implementation ChallengesImplementation Challenges

Education is a MUST!!!Education is a MUST!!!

Identifying a broad but focused group to drive Identifying a broad but focused group to drive implementation efforts will be criticalimplementation efforts will be critical

Variability of practices will cause challenges with Variability of practices will cause challenges with setup and maintenance of systemssetup and maintenance of systems

Process redesign will become a necessary Process redesign will become a necessary component of improvements and may be resistedcomponent of improvements and may be resisted

This will be more evident in EMR deploymentThis will be more evident in EMR deployment

Recognize and accommodate for go-live ‘slow Recognize and accommodate for go-live ‘slow downs’ and reduced productivitydowns’ and reduced productivity

““Nothing will ever be attempted if Nothing will ever be attempted if all possible objections must all possible objections must

first be overcome.”first be overcome.”Samuel Johnson