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Community Health Connections

IMPLEMENTATION PLAN

Version 5.1 4/06/2010

San Diego Community Health Connections

Healthcare Information Technology (HIT) Class

UCSD Extensions

Prepared By UCSD Extensions HIT Spring 2010 Class

Name/URL Josie Aguinaldo Nga Anamosa Victor Cecena Ras Desimone Lynda Flower Jean Frazier Warren Goldberg Jackie Harris Thomas B. Hoffman Sarah Leake Carmen Matthews David Montanez Mona Naoum Laurelle Palmer Sheldon Penner Luis Perez Regina Pizarro Ben de Rosales, Jr. Joel Salgado Jr. Kallya Shenoy Eric Smith Michael Tegardine DeEtte Trubey Carmen Valladolid Keri Vogtmann Thuan (Christopher) Vu Elizabeth Wellner Ann Marie Winclair E-Mail [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] Assembled By Mona Naoum & DeEtte Trubey

Implementation Plan

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1- Approval

Role Executive sponsor Visionary Project Manager Stakeholder 1 Stakeholder 2 Stakeholder 3 Name Signature Date

2-Version History

Version # 1.0 2.0 3.0 4.0 5.0 5.1 Implemented By Mona Naoum DeEtte Trubey Mona Naoum Mona Naoum Davi d Montanez Davi d Montanez Revision Date 03/07/2010 03/18/2010 03/20/2010 03/24/2010 03/31/2010 04/06/2010 Approved By PMO PMO PMO PMO Team Team Approval Date Reason EHR Implementation pl an

Updated content Updated content

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Table of content

1 Initiation...................................................................................................................................... 6 1.1 PURPOSE .............................................................................................................................. 6 1.2 DELIVERABLES .................................................................................................................... 9 1.3 CRITICAL SUCCESS FACTORS .............................................................................................. 9 1.4 PROJECT ORGANIZATION .................................................................................................. 10 1.5 ASSUMPTIONS AND CONSTRAINS ........................................................................................ 11 2 Pre-imple mentation planning ................................................................................................. 12 2.1 SYSTEM OPERATING ENVIRONMENT/ASSESSMENTS ............................................................ 12 2.2 SOFTWARE ......................................................................................................................... 16 2.3 HARDWARE........................................................................................................................ 16 2.4 RISK ASSESSMENT/MANAGEMENT STRATEGY .................................................................... 17 2.5 STAKEHOLDERS ................................................................................................................. 22 2.6 COMMUNICATIONS PLAN.................................................................................................... 23 2.7 MEANINGFUL USE .............................................................................................................. 25 2.8 FINANCIAL ROI SCHEDULE ................................................................................................ 31 2.9 REGULATORY COMPLIANCE ( RESEARCH & VERIFY) ........................................................... 31 2.10 HIPPA SPECIFIC COMPLIANCE .......................................................................................... 32 2.11 MASTER PROCUREMENT PLAN............................................................................................ 34 2.12 CONFIGURATION MANAGEMENT INTERFACE ..................................................................... 34 2.13 HEALTH INFORMATION MANAGEMENT .................................................................................. 34 3 Plan for Project Execution (Imple mentation plan)............................................................... 36 3.1 IMPLEMENTATION SCHEDULE............................................................................................. 36 3.2 POST- IMPLEMENTATION PLANNING .................................................................................... 37 3.3 FULL DESCRIPTION OF THE OPERATING ENVIRONMENT ...................................................... 38 3.4 HARDWARE (PER SITE) ....................................................................................................... 39 3.5 SOFTWARE ......................................................................................................................... 46 3.6 CLINICAL WORK FLOWS POST EHR................................................................................... 53 3.7 CLINICAL DECISION SUPPORT TOOLS ................................................................................ 61 3.8 TRAINING ........................................................................................................................... 66 3.9 CONFIGURATION MANAGEMENT P LAN .............................................................................. 69 3.10 PATIENT PORTAL ............................................................................................................... 73 4 Monitoring and Controlling .................................................................................................... 74 5 Closing/User Acceptance Testing ........................................................................................... 74 5.1 USER ACCEPTANCE TEST RESULTS .................................................................................... 78 6 Final project Wrap-up............................................................................................................. 80 6.1 MASTER PROCUREMENT PLAN ........................................................................................... 80 6.2 FINANCIAL ANALYSIS ........................................................................................................ 81 Appendices ................................................................................................................................... 84

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POST APPOINTMENT O RDER FORM ................................................................................................ 84 DIABETIC FLOW SHEET .................................................................................................................. 85 WELL WOMAN VISIT ENCOUNTER FORM ....................................................................................... 86 PROCUREMENT P LAN ITEMS .......................................................................................................... 87 FINANCIAL ANALYSIS FINAL ASSUMPTIONS .................................................................................. 88 MEANINGFUL USE TABLES ............................................................................................................ 89 FINANCIAL ANALYSIS CALCULATION DETAILS ............................................................................100

Implementation Plan

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1 Initiation

1.1 Purpose

Community Health Connections of San Diego (CHC) is a multi-center system of clinics that is proud to provide an extensive array of high-quality primary care services. Many of our patients qualify for free or low-cost services based upon their income and family size. As a safety-net provider many families count on our services to manage their episodic medical needs as well as their day to day health concerns. In an on- going effort to improve overall patient care, CHC has received high level support to acquire and implement an Electronic Health Records (EHR) system. The purpose of the project will be in alignment with the center's overall strategic plan: To deliver high quality medical services to the community To provide continuity of care and coordinate follow-up care Promote patient satisfaction

Our Mission & History Community Health Connections of San Diego is an organization rich in mission and history. Our mission is to provide comprehensive, accessible, quality health care services to residents, communities, and community-based organizations in San Diego and the surrounding region. We offer affordable services to all income levels, with a special commitment to low income, and uninsured individuals and families. Our history is a story-book fantasy comes true. The clinic was started by a visionary community worker in a small temporary trailer parked on a dusty lot. With years of hard work and support of strong partnerships and community activist it has now grown into a federally qualified community health center with three clinic locations (East, Central and West) and a mobile clinic for school program. Each clinic provides Adult Medicine, Women's Health and Pediatric services Adults Community Health Connections provides adult medicine at all of its primary care clinics. Specific services include:

Acute Care (Sick Visits) Case Management Chronic Disease Management - for conditions such as Diabetes, Asthma, and Hypertension

Women Community Health Connections offers an extensive array of women's healthcare services including:

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Breast Cancer Patient Navigator Program Breast & Cervical Cancer Screening Breast Clinic and referrals for mammograms for women over the age of 40 Colposcopy and LEEP surgery Free Pregnancy Testing Gynecological Services Lactation Education Prenatal Care Presumptive Eligibility for Medi-Cal Psychosocial Assessment & Counseling Ultrasonography WIC (by referral only)

Children Community Health Connections specializes in providing comprehensive medical and developmental services for children. Specific services include:

Acute Care (Sick Visits) Behavior Management Developmental Screenings, Assessments & Intervention Immunizations Physicals - School, Camp & Sports Screenings for Anemia, Lead, Vision, Hearing and Tuberculosis Speech/Language Evaluation & Therapy Well Child Exams

Pharmacy Community Health Connections operates a full-service pharmacy at Central Health Center. The pharmacy accepts most insurance plans and is only open to patients of Community Health Connections. Limited pharmacy services are available at other clinic locations for health center patients. Radiology Services Community Health Connections has basic radiology services at the Central Clinic location. Services offered include. Chest X-rays X-rays of the extremities and Abdomen Sinus Series Back and neck X-ray evaluation Ultrasound (pre-natal) Counseling/Mental Health Services Community Health Connections provides comprehensive counseling and mental health services for children and adults. Specific services include: Individual, Couples & Group Counseling

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Adult and Child Psychiatry Clinic, School and Home Based Services Court Certified Domestic Violence Treatment Program

Health Education Community Health Connections offers a wide range of health education services for children and adults, provided by a Registered Dietician, Nutritionists, and Health Educators. Individual and/or Group Sessions in English and Spanish are offered in the following programs: Healthy Beginnings Program for Infants 0-12 months - "Comienzo Saludable" Infant Feeding Lactation Education and Counseling Lead Poisoning Prevention and Education Parenting

Growing Healthy Program for Children - "Creciendo Saludable" Anemia Asthma Childhood Chronic Diseases Diabetes Eating Disorders Lead Poisoning Prevention and Education Nutrition Obesity/Childhood Obesity Prevention Education Parenting

Healthy Living Education Program for Adults - "Viviendo Saludable" Nutrition Chronic Diseases

EHR Implementation We now will embark on one of our most ambitions endeavors. Thanks to a 1.6 million dollar grant we are able to prepare Community Health Connections for the 21st century by implementing an electronic health record (EHR). This must be done in compliance of the Healthcare reform act to meet meaningful use criteria in order to qualify for the federally mandated incentive moneys. The financial windfall together with the improved delivery of care afforded by a well implemented EHR will result in better patient care. It is of utmost importance that our ROI goals are made clear. Not only will we benefit from the federal incentive, but also from other expected benefits such as: More satisfying work conditions Improved work- flow Improved patient satisfaction

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Decreased charting/prescribing errors Immediate access to lab results, and patient charts. No more lost charts Freeing up of space now used to store charts.

The implementation team will assign measurable parameters to these indicators to ga uze our ongoing success. The EHR implementation planning team will transition to implementing the final plan. The executive committee is wholeheartedly supportive of this effort and has already approved of the following software and systems. EHR - OpenVista www.medsphere.com DBMS - InterSystems CACHE www.intersystems.com Interface engine - mirth connect www.mirthcorp.com Health Information Exchange - CONNECT Gateway www.connectopensource.org Web-based patient portal to CONNECT Gateway Pharmacy ­ Surescripts Laboratory - (software) Radiology- (software) We will be fully integrated with local registries and hospitals. All system changes will be implemented through use of Plan Do Study Act (PDSA) process improvement methodology. Without a doubt implementation of the EHR will be a challenging process. However it will yield endless rewards. Not only in improved staff work satisfaction but also in our main mission, improved patient care.

1.2

· ·

Deliverables

A detailed implementation plan narrative and supporting documents for the systems selected by CHC A 2 hour presentation of the implementation plan to include all contributing members of the team for Executive and Board approval

1.3

· · · ·

Critical Success Factors

Full CEO support and involvement Clinical champion - Chief Medical Officer will lead the Implementation project. We recognize that an EHR is not an IT project, it is a clinical project with significant impact on the entire organization We have full C-level support and participation ­ All areas were consulted in the development of the plan ­ The plan was developed across organizational boundaries

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· · ·

­ Project team membership reflects the cross functional plan Organization is mature, unstable organizations have little chance of success Detailed information on how we will achieve a positive return on investment in an EMR will be presented later in the plan. Our organization has a culture of quality improvement already in-place (PDSA ­ plan, do, study and act).

1.4

Project Organization

Project team members are expected to work together (within their specialty and across all groups), to create a realistic, detailed Implementation Plan ready for the Executive Committee review on March 25, 2010. A PMO was set up on Feb 17, 2010, with representatives of the various specialty teams, to coordinate work necessary to create the requested Implementation Plan.

The Specialty Teams: Clinicians (clinic workflow, design of EHR components, data migration, process analysts) Hardware (technical integration, IT infrastructure acquisition and management, security, requirements management, run books)

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Software (configuration management, development, risk management, project management, deliverables).

The Project Manager, DeEtte Trubey, is hereby authorized to interface with management as required, negotiate for resources, delegate responsibilities within the framework of the project, and to communicate with all team members, to ensure successful and timely completion of the project. The Project Manager is responsible for assisting in the development of the project plan, and monitoring the schedule, cost, and scope of the project during implementation. Project Management Office: A PMO was created by the project manager and representative members of the Clinical, Hardware and Software Teams when the Executive Committee approved a project to create an EHR Implementation Plan. PMO Team Members: DeEtte Trubey David Montanez Kal Shenoy Keri Vogtmann Mona Naoum Project Manager Project Manager Software Team Project Manager Hardware Team Project Manager Process Team Project Coordinator

An Excel Spreadsheet has been created and distributed to the team to specify roles and responsibilities for team and cross team efforts. The CHC Executive Committee assigned the implementation development tasks to the members of the EHR Implementation planning committee on February 17, 2010 and expects a realistic, detailed Implementation Plan ready for their review on March 25, 2010. EHR Planning Committee members are assigned part time, to the EHR Implementation Planning Committee, in addition to performing their normal job duties for the duration of the 6 weeks planning process. They will present and gain approval for executing the Plan following the review.

1.5

Assumptions and constrains

Implementation project to begin Feb 2, 2010 and complete by Jan 20, 2010 Implementation will begin with Central Clinic for all specialties before moving on to West Clinic and then East Clinic Administrative offices are co- located with Central Clinic

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Must be compliant with Federal and State regulations, including meaningful use CONNECT Gateway will be used for patient access, Uniform Data System (UDS) reporting and updating the County Immunization Registry Existing use of the Patient Electronic Care System (PECS) registry will migrate to the EHR System changes implemented through use of Plan Do Study Act (PDSA) process improvement methodology CHC has at least 30% patient volume enrolled in the Medicaid program A train the trainer approach will be used to minimize vendor-related expenses

2 Pre-implementation planning

2.1

System operating environment/assessments

Data center recently rebuilt, co- located with the Central Clinic Plenty of floor space, power, backup power and A/C for all new equipment (rack mounted) and is fully HIPAA compliant Microsoft Operating Systems, prefer thin client user interface Separate network for EHR users New production, test, development (2), training environments needed Exam rooms use will be via convertible laptop/tablet computers Interface via HL7 w/PMS, LAB, RAD and PHM PHM to provide SureScripts e-prescribing LAB to provide HL7 interface to outside labs 99.9% uptime required Provider access from home or other locations required Full configuration management is required

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2.1.1 Evaluation of existing work flows

CHC currently employs a Practice Management System (PMS) for registration and billing services. The analysis of existing work flow shows areas where an EHR implementation will improve quality and patient safety. Current status makes the collection of data for billing, quality management, outcomes reporting, and resource planning very difficult to perform. (Sample billing and adult patient visit workflow are shown below)

Process/Approach:

Billing work-flow

Step 1: Scheduling Department Via phone:

New patient: Appointment scheduled. Demographics/insurance information obtained and entered into PMS software. Determine if referral or pre-authorization is necessary and, if so, has it been obtained. Established patient : Appointment scheduled. Recheck/update demographics and insurance information. If established patient, Chart Room notified of need to scan and abstract patient's records. Step 2: Front Desk Patient shows up for appointment. Encounter opened. Via Front Desk: New patient: Create patient MR number and verify insurance

Established patient : Recheck information and confirm accuracy If returning patient arrives without appointment, Chart Room notified of need to scan and abstract patient's records Collect co-pay and post in PMS (if applicable)

Step 3: Patient goes through visit as depicted in Adult Workflow Sheet In the Diagram below, the orange file symbols indicate paper record transfers of patient information across departments which allow for misplacing records and vital information as people search for lost charts and spend time clarifying orders, medications and documentation. Each department has an existing customizable paper superbill with the most common CPT and ICD-9 CM codes ready for easy check off, and the E&M codes list as per clinic and specialty; at level of Billing Department

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Step 4: Laboratory, Radiology and Pharmacy After Patient Encounter, appropriate charges migrate to PMS and charges generated.

Step 5: Billing Department Billing personnel review the bill for accuracy and send it to payer(s). Wait for payment and reconcile the Explanation of Benefits (EOB) and Accounts Receivable (A/R) using PMS.

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Workflow - wi th ou t EHR Practice Management S ystem (P MS ) in Place

Billing Wor kflow

MR pulls records for next da y patients.

Medical charts sent to PSR at Clinic for next day

PMS is utilized. - PSR schedules an appointment. - Demographics and Insurance info input or updated into PMS

List of next day patients generated .

· PSR Logs into PMS

and Prints daily schedule for providers. · Charts ready for today patient.

PSR performs task in PMS: s -Convert master ID to a patient Medical record #. -- If new registers patient in PMS and gathers information. I -- If existing, updates information . - Updates, Collects Deposit/Co-Pay and payer information. Posts in PMS

Patient checks in with PSR .

Patient is processed as per Ad ult patie nt Work-fl ow shee t.

T oward end of Patient encounte r.

Using paper Superbill: - input ICD9 & CPT codes entered. - Orders & procedures are checked off. - Places chart in Bin

Chart reviewed fo r accuracy of codes and Documentation.

- Completes and confirms all provider orders. - Makes copy of superbill to retain with chart . - Original sent to Billing dept.

-Data input into PMS

- Bill generated and checked for accuracy , sent to insurance co or correct entity.

Bill paid?

NO

EOB scrutinized and if necessary chart is pulled and notes sent . Bill resubmitted or adjusted

·

YES

Bill reconciled A/R adjusted. - End

Code for billing and diagnosis from the PIS, RIS and Pharmacy auto migrates to PMS

2.1.2 User needs (work flow re-design)

CHC is planning to deploy the OpenVista systems for its network of three ambulatory care centers and a mobile medical unit. The desire to improve patient care, reduce medical errors, increase organizational efficiency and meet federal meaningful use incentives are factors leading to the adoption. The OpenVista Clinical Information System, (CIS), component will implement the EHR for clinical care and operations. To make effective use of these systems will require the re-design and integration of all work flows. Key expectations from implementation are: Insuring seamless interoperability between OpenVista, the current LIS, RIS, Pharmacy IS system and the PMS to improve the quality and the speed of information and data available for patient care. Enhancement of the capabilities of document and record management through interface with the current Practice Management System (PMS). Implementation of Computerized Provider Order Entry (CPOE) and adoption of decision support tools and alerts for patient care. Improved reporting capabilities and utilization of preventive care statistics and incorporating PECS reporting system via an NHIN and CONNECT portal. Compliance with HIPAA Security Measures.

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As part of the EHR implementation plan, cross functional teams are evaluating the analysis of existing work flow with future systems to bring the most value where an EHR implementation will improve quality and patient safety.

2.2

Software

The following is the diagram for the community healthcare connections current software system showing connectivity.

2.3

Hardware

CHC has a network of three ambulatory care centers and a mobile medical unit. The clinics provide adult, obstetrics and pediatric health care. There are pharmacy, radiology and laboratory services with their information systems in place.

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Currently the Central clinic has the computer room that hosts applications supporting Laboratory Information System (LIS), Radiology Information System (RIS), Pharmacy Information System (PIS), Practice Management System (PMS) There is an existing communication network that connects three clinics ­ East, West and Central but the network capacity is almost to the limit. The review of the infrastructure indicates that adding any other application will require additional bandwidth or separate network configuration. There is also need for upgrading Server and storage environments.

2.4

Risk assessment/management strategy

Chief security officer will be responsible for overall risk management plan Threat ID Implementation: H/W delivery delays or prob. SW delivery delays or prob. Prob Impa ct Low Med Med Med Internal sabotage Low High User assigned wrong access

Implementation Plan

Plan to address threat

Plan adequacy

Have backup vendors Establish Pilot, Alpha and Beta cycles to minimize overall deployment risk Establish V1 and V2 release cycles with V1 focused on core feature set and V2 All departments perform beta testing Go/No-go gates in project plan Scheduled V2 release cycle Comprehensive test scripts Have consultant identified if needed Have plan to delay go- live, Protect H/W Disaster recovery plan restores data to recovery point Fire suppression system in data center to prevent fire damage Backup s/w nightly Security system should monitor all areas, camera in data center Keep backup personal briefed on project on routine basis Establish incentives for key success items to reward key resoruces Supervisors and security agree on access privileges for all employees.

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Users do not like final workflows

Low

High

Interface issues

Med

Med

Natural disaster

Low

High

Key Resource turnover

Med

Med

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privileges

Training on privacy ­ code of the ethics Reiterate that HIPAA covers computer privacy and paper records Network passwords must be changed every 90 days Mandatory training Super- users available in each department Reinforce privacy and security awareness Test during beta testing System Admin available during all hours Supervisors approve all rolls and privileges for their department Real-time monitoring on go- live date Up front communication on the benefits of the EHR deployment Department debrief meetings to address issues Conduct complete security audit on a yearly or on an as needed basis Conduct custom code review based on security standards One-on-one training by training team Include any "problem" individuals on beta testing team Have a respected person talk with individual Require an extra security question when accessing off-site Implement VPN or other process which requires additional passwords Network access audit trail ­ logs network access and uses Clearance procedures need to insure proper EHR rights are provided Develop roles/privileges for all access needs Develop process to immediately address any security issues

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Go-Live: User training issues

High Med

Rolls and privilege problems

Low

Med

Interface problems Poor organization attitude

Med Low

Med High

Ope rational: Unknown security issues arise

High Med

Poor adoption rates

Med

Med

Log-on/password is lost/stolen leading to improper access or use.

Low

High

Off-site unauthorized employee access to data

Low

High

Implementation Plan

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Offsite workstation/mobile devices left on risking improper use Virus contamination by offsite device Med Med Offsite device lost and unauthorized access occurred System goes down Med Med Person illegally enters area Med Med Workstation is stolen

Implementation Plan

Med

Med

Low

High

Data Corruption

Low

Med

Low

Med

Audit reports to help id device or user account used Session termination on inactive devices Similar defaults for all applications EHR access via Terminal Server session so critical patient data is not kept on the local machine Install personal firewall s/w on all laptops that access EHR Update virus s/w on all devices Restrict access to high risk internet sites. Educate employees that Internet downloads on in- house computers is blocked. No unauthorized software to be installed on in- house computers. Only IT Systems Admin can install h/w or s/w. Private data can only be stored on main system database Change password for owner of h/w Debrief with owner Prepare backup plan based on paper processes Hot backup process for main server Perform post-analysis of problem Daily incremental backups Weekly full backups Use more secure connections for email via SSL All Internet facing systems should require SSL Cameras to monitor all areas All employees responsible for monitoring Security cards plus code used to enter all secure areas and is controlled by access privileges. Facility key, Desk key, cabinet keys to restrict physical and data access. Visitor sign- in procedure Back-up media is kept in secured area Insure data is not on w/s, but remains on server Lockdown all stations in cart,

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Employee takes ePHI on movable media High High

Employee looks at ePHI without the need to know

High

High

Employee leaves

Med

Med

mobile clinic, exam rooms, and nursing stations Implement inventory control system Audit all systems at close of business Review video from security cameras Keep emergency backup workstations Access control to all areas W/S will have security screens to hinder "shoulder surfing Roles and privileges reviewed quarterly Employees to report any regulatory issues "high profile" people to be audited everyday Disable all USB ports, floppy drives, and CDR-DVDR drives where appropriate Prohibit storage devices from facility where possible Only allow cell phones, mp3 players and other devices with storage to be used in areas that do not have system access. HR/IT Process includes the elimination of all access privileges to all systems immediately. HR process to include discussion on regulations Full regulation training for all employees focused on using electronic system Full regulation training for all new employees Special training for all employees for any major changes Server organizational policy to have stiff penalties for even first time violators. Yearly refresh training for all employees

Regulation: EHR system has new regulatory issues Staff turnover New/Changing regulations Some employees do not take processes seriously Lost focus on regs Technical Safeguards:

Implementation Plan

Med

Med

Med Med Low

Med Med High

Med

Med

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Hardware failure & recycling

Med

Med

Inappropriate access through provider portal

Low

High

Inappropriate access through patient portal

Med

Med

Have spare hardware parts on site and current maintenance contracts with Data Center vendors Used faulty hard drives and other electronic media must be destroyed Hard drives must be reformatted before re- use (so that any prior data is securely removed.) Server monitor software will alert IT staff of equipment failures/warnings VPN client security & username/password providers 2 layer of authentication Remote access group membership required for VPN access adds another level of security Training of workforce members prior to granting remote access VPN client timeout on inactive connections Require 2 factor authentication Training for patient when access to Patient Portal is granted Patient will sign a waiver saying they understand that their password is for their use only.

Wireless communication breach

Low

Med

Wireless (Wlan) will use WPA cryptographic techniques WLAN connectivity requires authentication with username and password WLAN provides access only to the Internet (EHR on separate network) Access to EHR requires secure VPN connection

Network security breach

Low

High

Separate network for EHR A kiosk computer in the lobby cannot access EHR network Inventory all applications and hardware that have ePHI to ensure they are all on the separate network

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2.5

Stakeholders

A stakeholder is anyone who will be affected by the project. See communication campaign to see plan for each group. Appropriates Stakeholders will be interviewed and included in testing throughout the project. The project team must pay attention to potential employee sabotage, with possible reasons being: o Employee supported other solution for project o Change resistant o Scared of technology o Position at company at risk (formal or informal). Title Role Degree of Influence 9 9 10 Comments

Top Management Board Project Steering Committee Business Sponsor (Chief Medical Officer) Implementation team (Key) Project Manager Application Specialist Clinical Workflow Specialist

Ultimate responsibility Overall guidance & mgt oversight, compliment strategic vision Overall accountability for project

Manages overall implementation Provides content knowledge about use, design, and config. Understands healthcare processes

8 8 9 Super- users for Peds, womens, adult

EHR Vendor Consultants Mirth Vendor IT Team IT Manger Integration Architect Database Administrator System Administrator Network Administrator

Implementation Plan

Dev. resources if needed, best practices, fix s/w issues Experts in specific areas if needed Consulting where needed Overall responsibility from an IT perspective Overall IT architecture, dev, production, testing, & integration Tune and manage database Manage live system, file growth, provisioning, backup, etc Conduct site assessments, VPN installs, network configuration

6 6 6 9 7 6 6 5

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CIO

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Care givers Nurses Laboratory Head Radiology Head Mental Health Therapist Physicians Dietitians Pharmacy Functional Departments: Head of billing dept Training Specialist Customer Service ­ call center Head of Medical records Quality control/risk mgt Custome r: Patient Family External Community: Insurance Companies Government officials Community Volunteers Media

Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated Insures specific department's needs are accommodated

9 7 7 6 9 5 7

Head of Nursing

8 5 4 8 7

6 5

4 6 4 4

2.6

Communications plan

Situation Constant, effective communication among all project stakeholders is an essential factor leading to the success of a project. Sharing information and knowledge empowers every project member to perform tasks efficiently and timely. This communication plan will expect contribution of

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everyone involved in the project to: coordinate action, recognize and solve problems and react to changes during implementation of the OpenVista EHR.

Vision The implementation of the OpenVista EHR is intended to improve patient safety, reduce medical errors, reduce duplicate services and optimize reimbursement. The communication plan is expected to ensure that everyone involved understands exactly what can be accomplished within a given time frame and budget; a systematic method for establishing realistic goals for deliverables, cost, schedule, and quality. And techniques for keeping the goals consistent throughout the project. Communication A multi- faceted approach will be used for this implementation where communication will flow top-down as well as bottom-up. Upper management is expected to provide timely decisions that keep the project moving, to supply people and other resources, make policy decisions, or remove organizational obstacles. Clinician and administration feedback on concerns and improvements of system functionality, user interface, process and training is key for successful EHR implementation. Managing Change During the life of the EHR implementation, changes to the project scope, schedule and resources may occur. Sources to these changes can be internal or external. However, the source, managing and communication of change are keys to success. Types of anticipated changes are: Scope Creep, Schedule, Technical, Resources, Staff, Deliverables, and Process. Type of Communication Responsible Stakeholde r Communication Method

Community Clinic Marketing and Information Meaningful Use Compliance and Promotion Patient Care Improvement Communicating Key Project Status Assuring Support for Project Compliance and Regulations Press Releases Incentive & Recognition Programs

Public Relations

Email Website Newsletter Public Service Announcements Government Agencies Email All- hands Meeting Government Agency Conferences

C Suite/Senior Management

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Project Status and Schedule Maintain Organization Chart and Responsibilities Project Milestones (Go/No Go) Issues and Resolutions Implementation Advocate Healthcare Rules, Policies Clinical Information

Project Manager

Email Meetings Project Website

Clinicians

Email Meetings Verbal communication

2.7

Meaningful use

Meaningful Use and the American Recovery and Reinvestment Act of 2009 CHC has elected to be reimbursed via HITECH Act's Medicaid Physician Reimbursement Plan which begins on January 1, 2011 (Meaningful Use Appendix Tables 1 and 2). Since CHC will qualify for Medicaid incentive payments, CHC will waive their right to receive duplicative Medicare payments and demonstrates that it meets the minimum Medicaid patient caseload of 30%. In order to qualify for incentive payments, CHC will meet the following four criteria: 1. Demonstrate "meaningful use" of a certified EHR technology. (Meaningful Use Appendix Table 3) Meaningful use will be divided into 3 stages starting 2011 through 2015. At present this means making sure that the EHR system will meet the 25 criteria for stage 1 meaningful use to include necessary numerators and denominators for required percentages under meaningful use (Meaningful Use Appendix Table 4). The goal of 2011 and 2013 objectives is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions. 2015 objectives goal is to achieve and improve performance and support care processes on key health system outcomes (Meaningful Use Appendix Tables 5 and 6). 2. The EHR will provide features that enable electronic prescribing. 3. The EHR system will be connected and support electronic exchange with other health systems. 4. The EHR will be able to perform electronic data interchange of clinical with applicable networks and report on quality measures. In 2011, all meaningful use will be done by attestation; in 2012 in addition to attestation, quality data will be required to be submitted electronically. Post 2012 would require electronic submission of all quality data. The highest incentives will be available from 2011 to 2013. Additional but reduced incentives will be available in 2014 and 2015. The Medicaid EHR incentive program provides incentives payments to eligible professionals and hospitals for efforts to adopt, implement or upgrade certified EHR technology in the first year. By the second year providers must prove they meet meaningful use. Thereafter, eligible providers must prove they qualify for up to an additional five years. Practices with multiple physicians will be eligible to receive incentive payments for each provider. In the first qualifying year, only 90 days of meaningful use data is required to qualify for incentive payments. After the first year, the EHR reporting period for meaningful use

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is extended to a full 12 months. A payment year equals a calendar year. Incentive payments for meaningful use end after 2016. Challenges Some of the challenges include: the cost to implement and maintain the EHR system; the interoperability and health information exchange capabilities of individuals and organizations participating in such an exchange; and ensuring the EHR system is implemented in such a way that the staff can make full use of its capabilities. To meet these challenges CHC and eligible providers will work together on assessing needs and setting goals to obtain beneficial results and continue to meet meaningful use criteria by adjusting processes and organizational governance as necessary to achieve those goals. In addition, now that the system is in place and is enabled to be used effectively we have the human element. The question becomes will the system be used effectively by staff for the purpose of delivering quality of care and service? This part can be addressed through a process of staff education and training on the subject, its process, policies and procedures. Finally, how do we keep track of crucial matrix criteria and are flexible enough to ensure we are meeting "meaningful use" so we can continue to receive funding for the allotted period of time, especially considering the fact that not all criteria has been defined for future stages. This latter point will entail a joint effort and ownership by staff and management of various departments, along with policies and procedures that have been established as well as ongoing process improvements of workflow to make and implement any necessary changes as criteria becomes defined (Meaningful Use Appendix Table 6).

Long Term Benefits of imple menting and maintaining EHR In addition to the $1.6M grant received to help with the installation of an EHR system that will allow CHC to meet meaningful use criteria, the Medicaid EHR incentive program offers additional incentives, opportunities, and funding necessary to allow for the adoption and maintenance of health information technology. Some of the long term benefits of having an EHR system in place include: improving clinical processes and workflow efficiency, improving quality of care by decreasing costs and duplicity, sharing patient record information with healthcare practitioners and professionals, reducing medical errors through evidence-based decision support, quality management and outcomes reporting. Satisfying Meaningful Use Stage 1 Crite ria Of the 25 meaningful use criteria 8 are an integral part of OpenVista and will be incorporated: CPOE, drug-drug interactions, an active problem list, e-prescribing, active medication and allergy list, Vital Signs and Smoking Status will all be a part of required fields that can be filled or where data migration can occur from other existing program. For example: medication list will migrate from the existing Pharmacy Information System (PIS). The responsible party will be the Medical staff involved in taking the patient history a nd doing Vital Signs. Five of the meaningful use requirements will be met by the integration of data that already exists from current Information System program: demographics, electronic insurance eligibility and claims processing have been and will continue to be performed in the PMS system. The Medication reconciliation requirement is part of the PIS.

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The CONNECT portal will facilitate the reporting of: the immunization registry, CCR for syndromic reporting, quality metrics to local and international registries, payor or federal/state regulatory agencies, and allow for the exchange of key information with other healthcare providers. Responsibility of reporting will be a joint effort between the QA department and healthcare providers. The patient is engaged and will be empowered with greater access to their healthcare information via a secure internet patient portal and with written consent will have the ability to access an electronic copy of their record within the federal mandated time limit or a paper copy if requested. Medical records personnel will be vital to fulfilling this function. Solutions: To help offset the implementation and adoption cost the Medicaid EHR Reimbursement program offers a one time, start-up incentive where the State will pay up to 85% of the average cost of a EHR not to exceed $25,0000 for purchase and initial implementation or upgrade of a certified EHR technology including support services and training. After receiving startup funds, for providers who can prove "meaningful use" the law provides up to $63,750 in federal contributions towards the adoption, implementation, upgrade, maintenance, and operation of certified EHR technology for eligible professionals. Up to 85 percent of $25,000, or $21,250, subject to a cap on average allowable costs, is provided to eligible professionals to aid in adopting, implementing, and upgrading certified EHR systems. Additionally, up to 85 percent of $10,000, or $8,500, is provided to eligible professionals for purposes of operation and maintenance of such systems over a period of up to five years. CHC presently employs 39 eligible professionals, 16 physicians and 23 nurse practitioners. (Meaningful Use Appendix Table 1 and 2) Information exchange still poses some challenges depending on who the sender and receiver is and whether or not their system is set up to import and process information received. In some cases information exchange is limited because frankly the infrastructure is either incomplete or lacking. In such instances we are still dealing with having to fax results and then having to import file into the system. On our end, attestation will be carried out via secure patient portal until 2011. Beginning 2012 all quality data submissions will be via electronic submission. All information exchange will be compliant with 45 CFR (Code of Federal Regulations) part 164 (HIPPA Security Rule) and HITECH Act Regulations Section 170.210 (Standards for health information technology to protect electronic health information created, maintained, and exchanged). CHC will also be compliant under 42 CFR Parts 495 (Certified EHR Technology for providers participating in either Medicare or Medicaid program and Meaningful Use). To track and monitor meaningful use (MU) compliance an FTE will be brought on board to help implement MU infrastructure. This will aid in the long term monitoring of updates and compliance throughout the stages of the EHR Incentive Program. This will also entail a collaborative effort between the management of respective departments and MU specialist to ensure criteria is being met and compliant to guidelines. In additio n, this collaborative effort will entail working together to develop policies and procedure guidelines and continual process improvement of workflows to facilitate a system that will be in place to allow the meeting and satisfying of criteria for future stages that is still under development.

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Assumptions: 1. CHC has at least 30% patient volume enrolled in the Medicaid program. CHC employs 39 eligible professionals. Physicians and nurse practitioners are eligible professionals. CHC eligible professionals qualify for one-time start up incentive in addition to regularly scheduled EHR meaningful use Medicaid incentive payments. EHR is implemented by December 2010 to qualify for one time start up incentive. First year meaningful use is established by 2011 with 90 days required quality data for first year's required EHR reporting period. Thereafter, data, reports and test will be completed on a full year (12month) basis. 2. Five Clinical Decisions Support for CHC are: Obesity, Hypertension, COPD/Asthma, Diabetes, Hypercholesterolemia 3. Our EHR will meet all 25 Meaningful Use Stage 1 criteria. 4. Initially, attestation will be carried out via secure portal. Beginning 2012, all quality data will be submitted electronically as noted in proposed rule of Federal Register II (A) (3). All information exchange will be compliant with 45 CFR (Code of Federal Regulations) part 164 (HIPPA Security Rule) and HITECH Act Regulations Section 170.210 (Standards for health information technology to protect elec tronic health information created, maintained, and exchanged). CHC providers will also be compliant under 42 CFR Parts 495 (Certified EHR Technology for providers participating in either Medicare or Medicaid program and Meaningful Use). CHC's MU certified EHR is also compliant with the fair data sharing practices outlined in the Nationwide Privacy and Security Framework. 5. CHC has extensive Quality Management processes in place. Even so because of the complex nature and infancy in development of meaningful use an FTE will be brought on board to help implement MU infrastructure. This will aid in the long term monitoring of updates and compliance throughout the stages of the EHR Incentive Program. 6. A system will be in place to track MU use of certified EHR technology by providers to ensure that such use of funds and resources is consistent with federal rules. Presently, a system will be under development during the implementation phase. 7. To be fully eligible for incentive payments, CHC's certified EHR technology will be compatible with State and/or Federal administrative management systems. In addition,

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CHC already complies with existing Federal/State data interchange requirements, electronic billing and payment processing for Medical and Medicare.

MU Appendix Table 2 Meaningful Use EHR Incentives Payment Scenarios for Medicaid EPs Who Begin Adoption in the First Year Calendar Year Medicaid EPs who Begin Adoption in: 2011 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Total $63,750 $63,750 $63,750 $63,750 $63,750 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 2012 2013 2014 2015 2016

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MU Appendix Table 1 Meaningful Use EHR Incentives

Maximum Incentive Payment Amount for Medicaid Professionals Maximum 85% Allowed for Cumulative Eligible Incentive Over Professionals 6 - Year Period $21,250 $8,500 $14,167 $63,750

Cap on Net Average Allowable Costs, per the HITECH Act

$25,000 in Year 1 for most professionals $10,000 in Years 2-6 for most professionals $16,667 in Year 1 for pediatricians with a minimum 20% patient volume, but less than 30% patient volume, Medicaid patients $6,667 in Years 2-6 for most professionals pediatricians with a minimum 20% patient volume, but less than 30% patient volume, Medicaid patients

$5,667

$42,500

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2.8

Financial ROI schedule

Data has been collected and will continue to be collected and analyzed to determine the return on investment following the implementation of an EHR system. The final section of this plan will show the results.

2.9

Regulatory compliance (research & verify)

Regulatory Level Federal Federal Federal Federal

Name

Legal and Regulatory Requirements HIPAA Health Insurance Portability and Accountability Act of 1996 PSQIA Patient Safety and Quality Improvement Act of 2005 ARRA American Recovery and Reinvestment Act of 2009 HITECH Health Information Technology for Economic and Clinical Health Act

Description Privacy Rule and Security Rule Patient Safety Rule Meaningful Use Reimbursement Initial Set of Standards and Certification Criteria Interim Final Rule HHS Authority and Breach Notification Interim Final Rule Certification Programs ­ Notice of Proposed Rule (NPRM) State Health Information Exchange Cooperative Agreement Program Health Information Technology Extension Program Title 42 ­ Public Health Compliance Oversight Title 16, Title 17, and Title 22 Access Laws on Health and Safety Regulations for Health Facilities and Medical Services Documentation and Medical Record Requirements Federal Rules of Admissibility and Electronic Discovery Civil Rule 2006 Additional Discovery Rules for Legal Records, both Paper and Electronic

Federal Federal State State

CFR

CCR CHSC

Code of Federal Regulations Office for Human Research Protections (OHRP) California Code of Regulations California Health and Safety Code Joint Commission of 2004 Federal Rules of Civil Procedure

National Federal

JC FRCP

State

COAL

California Office on Administration Law

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2.10 HIPPA Specific Compliance

Overvie w: The Security Officer will be ultimately responsible for a ll security issues. CHC is an organization that has a strong culture of security and : Aware of the exact documented process to protect ePHI All individuals are responsible for themselves and for reporting any issues All processes are documented and access provided to all employees via the secure intranet All processes are reviewed on an annual basis General Security Standards: Ensure the confidentiality, integrity, and availability of ePHI Protect against any reasonable threats to the security/integrity of such information Protect against any anticipated, non-permitted uses of confidential information Security Standards: Administrative safeguards: The Security Officer will be ultimately responsible for all security issues. Perform Risk Analysis (see Risk Analysis section) Implement measure to address high probability/high impact risks See risk analysis section Assigned Security Responsibility Each area such as nursing, admissions and billing have one identifiable employee responsible for security Workforce security Individuals are assigned a specific role and privilege for access to ePHI data o Supervisor and Admin approval required for access level changes o In- house tracking process will be developed. HR process includes deactivating terminated employees from systems Harsh penalties for violations o Most probable outcome being termination o Violations will be reported to state agency Conduct continuous audits of activity and access looking for unusual activity, access issues, or other non-compliant activities. o Should review at least 1% of data every year Security awareness & training for: All employees before going live, during major changes, and yearly retraining Newly hired employees Terminated employees cautioned on need to adhere to policy All contractors, agents, or others who are constantly at the facility Security incident procedures Address all security incidents, modify processes and communicate changes when required. Notify state agency when appropriate. These reports can be generated routinely during annual audits or on an a per-incident basis Contingency plan

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Contingency plans will be developed for data backup, disaster recovery, emergency mode operation, testing and revisions, and application/data criticality analysis. Evaluation Quarterly evaluation of risk management plan and all processes in first year, or on an as-needed basis. The decision to adjust the evaluation process will be made at the end of the first year. Process required to approve all business relationships that require exchange of ePHI Formal contracts will be approved by CFO and legal team Contracts must be signed by CFO if ePHI data is to be exchanged. Physical safeguards: Facility Access Controls Badges with pictures are used with a manual code based on roles a nd privileges to enter all secure areas CIO approval required to have access to all contingency operation areas Documentation on access privileges will be kept for 6 years Routinely assess facility to identify any risks for entry or theft Provide "Visitor" badges that provide access to limited areas Documentation for all hardware maintenance is maintained on secure portion of network Media controls Disallow any movable media into facility with a clear policy Cell phones, MP3 players should not be used near any data access points unless approved by the Security Officer Process required for all ePHI media which will be disposed or reused. o Documentation for all h/w and media moved including the individual Backup exact copy of ePHI before media is removed Workstation Use: All hardware maintenance only to be done by approved IT personal Workstation screen shields that stop viewing from angles must be used Access only the patient data that is required for your responsibility Patients can view medical record though a patient portal located in the admissions area. Technical safeguards: Access control User ID and 10 digit password using high security requirements will be used to log on to o Rules prohibit ID/pw sharing, writing down, and require changing it every 6 months Each user will be assigned a role/privilege approved by their superior and the system administrator which has been assigned to this process. Users are automatically signed off in 10 minutes Audit trails: Existing system/process currently used to track assets, will be used to track all new hardware. Implement system that can detect and track network intrusions

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Processes must be checked to insure data cannot be improperly altered or destroyed Transmission security Security measures must be used to insure transmitted data is not altered All transmitted data must be encrypted Firewall Protection: A firewall is to be installed separating the internal network from the internet Virus Checking: All internal workstation and external workstations that will be used for remote access will have approved virus s/w installed. Remote access security: Two factor authentication will be required for all remote device login VPN access for all remote login, but no data will be resident on remote devices Login becomes inactive after 5 minutes of inactivity. Approved virus software required.

2.11 Master procurement plan

In support of the CHC EHR implementation plan, various hardware, software and resources will be identified and requested by the various project teams. Timely procurement and delivery of the items is essential to follow the project implementation schedule. A goal is to ensure excellence in procured items while minimizing expenditures. Tradeoffs or substitutes of equipment may occur, but the expected benefits of the project cannot be sacrificed, such as: 1) patient quality, 2) responsiveness to patient needs, 3) improvement of staff efficiency and 4) system/hardware reliability. Details of the procurement plan will be listed later in this document.

2.12 Configuration Management Interface

Configuration Management is set-up to control of changes made to hardware, software, firmware, documentation, and test documentation throughout the life cycle of our current systems. It will be explained further in greater detail in the implementation section.

2.13 Health information management

Data Migration Curre nt Situation CHC currently utilizes computerized PMS, LIS, RIS and PIS systems which share data through a Mirth Connect integration engine. Clinical information is stored in paper charts maintained in chart rooms at each of the three clinic locations.

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CHC has been in operation for over 30 years and currently serves approximately 145,000 patient visits annually. That's a lot of paper! The Challenge With the addition of the OpenVista EHR system, we must populate the new EHR database with the information it will need to effectively replace the paper patient charts currently in use. The amount of data to be added to the EHR database is extremely large. Transferring all the data currently in paper form prior to roll out of the EHR would be prohibitively expensive and timeconsuming. The Cache database that stores the data for the EHR is separate from, structured differently than and completely unaware of the PMS, LIS, RIS and PIS systems containing much of the data required by the EHR. Solution Pre-Rollout Electronic Data Sources: The IT staff will configure the Mirth Connect integration engine to enable bi-directional communications between the existing PMS, LIS, RIS and PIS systems and the EHR. Further, they will configure each of these applications to alert Mirth Connect when data is added, modified or deleted so that it can initiate data transfers among the respective databases. Paper Data Sources: A list of patients whose records are to be migrated into the EHR prior to roll-out will be compiled, consisting of patients that can reasonably be expected to come to the clinic sooner rather than later, including: Patients who have scheduled appointments; Female patients who are pregnant; Patients whose primary physicians request they be migrated prior to rollout; Patients who have visited the clinic within the past year and are listed in the PECS Registry.

During the testing and training phase, the abstractors in each of the clinics will begin scanning and abstracting data from the paper records of the patients earmarked for pre-rollout migration. Post-Rollout Electronic Data Sources: All post-rollout data transfers between the EHR and the PMS, RIS, LIS and PIS systems will occur automatically, triggered by events such as the entry of a patient appointment or a lab result, per configuration applied pre-rollout. Paper Data Sources: Patients will be added to the EHR on a "go- forward" basis when they schedule their first post-EHR appointment or appear at the clinic or when a new patient's records are received from prior providers. Abstractors will scan and abstract data from paper records into EHR according to the Data Migration Table in Attachment 1.

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After patient's data has been migrated, patient's primary physician will inspect the resulting electronic record and either sign off on it or require that it be returned to the abstractor for corrections or additions. When a primary physician has approved an electronic record, the paper record is removed from the chart room and deposited in the off-site storage facility where it will be held for the mandated 7 years, then destroyed per HIPAA protocols. Three years post- implementation of EHR, any remaining paper records will be placed in long-term storage without abstracting and scanning. Patients appearing at the clinic after that time will be treated as new patients. Assumptions: Mobile unit has remote access to EHR as well as PMS, PIS, LIS, RIS systems. PMS, LIS, PHM and RAD systems have messaging capability that can be used to notify Mirth interface engine of patient records to be transferred Abstractors/scanners have access privileges for input to EHR One abstractor at each clinic location with extra at central (4 FTE times 2 years, then 1 FTE

times 5 years) Archive space off-site has been acquired for paper records after scanning/abstracting

(1000 square feet climate controlled) High speed scanner in administration of each clinic

3 Plan for Project Execution (Implementation plan)

3.1 Implementation schedule

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3.2

Post-implementation planning

Project Management Institute's Project Best Practices provides that the following two procedures to be performed in order to close out an entire project or project phase:

Administrative closure Contract closure

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Planning for these procedures early in the project will guide us in project closeout and make sure that nothing is accidently overlooked. This step is considered as Post-Implementation Planning. Following the procedures will help transition the project to the Community Clinic business and realize true project success. We will need to educate our sponsors & stakeholders to see the project complete at the end of the post- implementation phase, not at go- live.

When we finally get to the project closure, we want to verify key activities:

Has all remaining work been transitioned? Has staff performance been reviewed? Have all issues been closed? Have all action items been closed? Have all change requests been filed? Has all product documentation been received? Has the stakeholder agreed to the transition levels? Does the stakeholder recognize that all work has been completed? Have all financial books been closed? Has a project review been conducted and documented? Have stakeholder comments been gathered? Have contracts been closed-out? Have all formal approvals been received?

Finally, we will need to capture all "Lessons Learned" to become part of the CHC Project Archives for Best Practices, that will be reviewed for any applicability before other projects are planned.

3.3

Full description of the operating environment

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Figure 1 Technical Architecture

3.4

Hardware (per site)

After the review of the current IT infrastructure, the hardware planning team decided to recommend network and hardware upgrade for deploying EHR application. It will provide scalability for servers, storage and bandwidth requirements. It will also help in maintaining HIPAA requirements by enhanced security measures. The updated technical architecture includes ( see Technical Architecture) a Fiber ring network topology with connections to all three clinics. The current network will continue to function as is until after the EHR is implemented in production. After six months of EHR operation the access to current applications (LIS, RIS PIS, PMS and other small applications) will be switched over to the Fiber Ring network(see Network Topology).

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Figure 2 Network Topology

The main servers and storage systems supporting the EHR will be located in the Central Clinic (Main Center) with backup systems in the East Clinic (Backup Center). The nightly tape backup process will be run in the Backup Center to minimize the impact on the primary production environment(see Multi-site Clustering). A simpler version of ILM (information Life Cycle Management) process will be followed to minimize initial investment costs. There will be daily (incremental), weekly (full) and monthly (full) backups performed. Daily backups are retained in the Primary Center and weekly tapes are shipped to offsite storage with 30 day retention. Monthly tapes are also shipped to offsite with 12 month retention period.

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Figure 3 Multi site Clustering

Internal access to EHR application from three clinics will be through Thin Client technology, disabling ability to store any patient health information in the local workstations. Computer on wheels devices will be used in clinical areas with secure wireless connections. Remote access for authorized providers and IT support team will be handled through secure Virtual Private Network (VPN) with additional authentication through RSA token verification. Patients and providers will have access to authorized patient records through new Web Portal configured with Secured Sockets Layer (SSL) encryption Benefits The recommended architecture gives following advantages

Scalable network bandwidth. Scalable Servers and Storage Good failover environment for EHR production. Incorporates Security requirements for HIPAA requirements.

Process/Approach Order the servers : Estimated delivery time is 3 weeks.

Order Fiber network: Network installation and availability in 4 weeks. Installation process: o Install and configure Demo environment - release to the Development team o Install and configure Development environment.

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Test and release it to the development team.

o Install and configure Testing/QA environment Test and get ready o Install and configure Training environment Test and get ready o Install and configure production environment Test and get ready Assumptions There will be selective connectivity initially between current environment and the new network. Demo and development environment will be available in 6-8 weeks after the start of the project. Critical Servers are setup in clustering mode to provide high availability in the Primary Data Center. East Clinic Data Center (Backup Center) will be used as the standby operating environment (passive mode) in case of Primary Data Center failure. Software Installation: The following software applications have been selected for the EHR solution: InterSystems Caché OpenVista Server OpenVista CIS Mirth Connect CONNECT The selected applications are available for free download on vendor's website. Because the EHR system will utilize thin-client workstations, each application will be installed at the server level. Application settings will be configured as needed during the system configuration process. To verify and test that the applications have been installed, each application must have the ability to be launched and configured accordingly. Permanent clinic I.T. staff will have an active role in the installation process ­ this will enable I.T. staff to obtain necessary skills for postimplementation support. Software Installation Assumptions: New server(s) will be installed ­ no existing server for EHR (OpenVista) application. New thin-clients will be installed ­ no existing clients for EHR (OpenVista) application. Software applications will be installed at the server level ­ the selected applications will not be installed on the clients. Mirth Connect integration engine already in place for existing systems. Estimated time for installation 1 FTE at 1 day/8hours. Software Installation Process:

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Installation Server Verify installation of MS Server Install InterSystems Caché Install OpenVista Server Install OpenVista CIS Install CONNECT Client Verify installation of MS Windows Operating System Configure (installation) Each application will be installed in accordance to vendor requirements and specification. Verification and Testing To test and verify installation, each application must have the ability to be launched and/or connected to appropriate server. The applications must also be able to be configured as needed. Release for production (configuration) Upon completion of the software installation process, the system will be turned over to configuration management. Software Description: Intersytems Cache: InterSystems Caché® is a new generation of ultra- high-performance database technology. It combines an object database, high-performance SQL, and powerful multidimensional data access ­ all of which can simultaneously access the same data. Data is only described once in a single integrated data dictionary and is instantly available using all access methods. Caché provides levels of performance, scalability, rapid programming, and ease of use unattainable by relational technology. But Caché is much more than a pure database technology. Caché includes an application server with advanced object programming capabilities, the ability to easily integrate with a wide variety of technologies, and an extremely high-performance runtime environment with unique data caching technology. Caché comes with several built- in scripting languages: Caché ObjectScript, a powerful yet easyto-learn object-oriented programming language; Caché Basic, a superset of the widespread Basic programming language, including extensions for powerful data access and object technology; and Caché MVBasic, a variant of Basic used by MultiValue applications (sometimes referred to as Pick applications). Other languages, such as Java, C#, and C++, are supported through direct call- in and other interfaces, including ODBC, JDBC, .NET, and a Caché-provided object interface that allows accessing the Caché database and other Caché facilities as properties and methods.

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Caché also goes beyond traditional databases by incorporating a rich environment for developing sophisticated browser-based (Web) applications. Caché Server Pages (CSP) technology allows the rapid development and execution of dynamically generated Web pages. Thousands of simultaneous Web users can access database applications, even on low-cost hardware. For non-browser based applications, the user interface is typically programmed in one of the popular client- user interface technologies, such as Java, .NET, Delphi, C#, or C++. Best results (fastest programming, greatest performance, and lowest maintenance) are usually obtained by performing all of the rest of the development within Caché. Ho wever, Caché also provides extremely high levels of interoperability with other technologies and supports all of the most commonly used development tools, so a wide range of development methodologies are available. OpenVista Server: OpenVista Server is an Electronic Health Record (EHR) and Health Information System (HIS) derived from the VA Freedom of Information Act (FOIA) VistA server release and includes defect corrections and a selection of commercial enhancements equivalent to what has been released at Medsphere client sites.. OpenVista CIS: OpenVista Clinical Information System (CIS) is a cross platform frontend for OpenVista Server based on C# and Gtk# / GTK. CIS runs on the MS and Mono .NET frameworks. It is based on the design of the VA's Computerized Patient Record System (CPRS) and includes image viewing and other Medsphere commercial enhancements. Mirth Connect: Mirth Connect is an open source standards-based healthcare integration engine. Mirth Connect facilitates the routing, filtering, and transformation of messages between health information systems over a variety of protocols (like LLP, Database, and FTP) with support for numerous standards (such as HL7, XML, and DICOM). Mirth Connect consists of the Mirth Connect Server, Mirth Connect Admin istrator, and Mirth Connect Server Manager. Mirth Connect Server contains the back-end for the management interface and the integration engine component, which performs message filtering, transformation, and transmission. Mirth Connect Administrator is the graphical user interface that connects to the Mirth Connect Server and allows you to configure interfaces, monitor interface activity, and browse the message store. Mirth Connect Server Manager is a Windows-only graphical user interface that manages the Mirth Connect service, displays log files, and contains other configuration settings for the Mirth Connect Server.

CONNECT: CONNECT is an open source software solution that supports health information exchange ­ both locally and at the national level. CONNECT uses Nationwide Health Information Network

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(NHIN) standards and governance to make sure that health information exchanges are compatible with other exchanges being set up throughout the country. This software solution was initially developed by federal agencies to support their health-related missions, but it is now available to all organizations and can be used to help set up health information exchanges and share data using nationally-recognized interoperability standards. CONNECT can be used to:

Set up a health information exchange within an organization Tie a health information exchange into a regional network of health information exchanges Tie a health information exchange into the NHIN

By advancing the adoption of interoperable health IT systems and health information exchanges, the country will better be able to achieve the goal of making sure all citizens have electronic health records by 2014. Health data will be able to follow a patient across the street or across the country. Three primary elements make up the CONNECT solution:

The Core Services Gateway implements the core NHIN services enabling such functions as locating patients at other health organizations within the NHIN, requesting and receiving documents associated with the patient, and recording these transactions for subsequent auditing by patients and others. Other features include authenticating network participants, formulating and evaluating authorizations for the release of medical information, and honoring consumer preferences for sharing their information. New services will be created and current services will be enhanced as the NHIN interoperability specifications continue development in the coming months and years. The Enterprise Service Component (ESC) provides default implementations of many critical enterprise components required to support electronic health information exchange, including a Master Patient Index (MPI), Document Registry and Repository, Authorization Policy Engine, Consumer Preferences Manager, HIPAA-compliant Audit Log and others. Agencies are free to adopt the default enterprise component implementations packaged in the CONNECT ESC or to plug in existing agency implementations of these service components. This component also includes a software development kit (SDK) for developing adapters to plug in existing systems such as electronic health record solutions to turn on information flows to support the secure exchange of health information across the NHIN. This makes CONNECT a platform for participation in health information exchanges. The Universal Client Frame work contains a set of applications that can be adapted to quickly create an edge system, and be used as a reference system, and/or can be used as a test and demonstration system for the gateway solution. This makes it possible to innovate on top of the existing CONNECT platform.

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3.5

Software

EHR Solution ­ OpenVista CIS and Intersystems Cache CHC will install OpenVista CIS together with Intersystems Cache as our solution for automating patient health records. Some of the enhancements that OpenVista CIS will provide are as follows: Improve patient care by providing a snapshot of the overall clinical status of the patient, including results from the current pharmacy (PIS), lab (LIS) and radiology (RIS) systems. Billing information from the patient visit and any LIS, RIS or PIS charges will automatically flow back to the PMS system for easier billing. Clinical alerts, reminders, problems, vital sign information will all be easily accessible to providers. A Clinical Image Viewer will be available for radiology results. Consults will be created and tracked, with access to this data by both clinicians and the patient. Meet Medicare/Medicaid mandates. The OpenVista CIS application meets Meaningful Use requirements, and is also compliant with HIPAA standards.

Implementation Strategy Process improvement methodology of Plan Do Study Act (PDSA) will be used as part of the iterative software development life cycle process (SDLC). The development team will work with the key users to plan the change, test it, observe the results and act to keep or adjust the change. The PDSA cycle will guide our SDLC process as follows: Plan- Analysis/Design Review current system architecture, analyze new system components to be installed, analyze software requirements and clinical re-design specifications, perform gap analysis, and design custom development requirements.

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Do ­ Coding/Testing Configure and execute coding per design specifications on a small scale by logical work unit or functionality of the system. Immediately test changes with users to confirm the plan.

1) Install OpenVista CIS on application server 2) Install Intersystems Cache on the database server 3) Convert sample patient data from PMS to test data for OpenVista. Data will be sanitized to comply with privacy and security requirements as specified by HIPAA. 4) Migrate test sample patient data from PMS to initiate Cache database and launch OpenVista CIS app. 5) Support the Clinical Team in system configuration tasks relating to workflow ­ including templates, orders, order sets, reminders, and alerts. 6) Test activated CIS features and functions, including assura nce of HIPAA and meaningful use compliancy.

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7) Test interface connections between PMS and CIS, specifically ADT admit, SIU scheduling and DFT billing transaction messages. 8) Test interface connections between CIS and first ancillary service, such as LAB. Messages to be tested include ORM orders, ORU order results, DFT billing transactions, SIU scheduling. 9) Test interface connections between CIS and subsequent ancillary services, including ORM orders, ORU order results, DFT billing transactions, and SIU scheduling. 10) Test UDS reporting process. 11) Test HIE connection for transmitting immunization data to SDIR. 12) Test Patient Portal, and CCR transmission to HIE. Perform integration testing after OpenVista has gone thru several PDSA cycles and is accepted by the users. Study ­ UAT/Validate/Peer Review Study and validate the test results to ensure change met the requirements and quality expectations. Work with users to identify issues/concerns and plan accordingly. Perform QA/peer review of the final work product before attempting the next iteration. Test data will be reviewed and validated. CIS features and functions also will be validated. Act ­Implement/Support After testing and refining each unit of work on the system through the PDSA cycle, implement the change in the steps. OpenVista will be implemented first. Integration with PMS Practice Management System will be the next step, followed by integration with LIS, RIS and PIS. HIE connections to SDIR and Patient Portal will be final steps. Continue support and process improvements will be applied as necessary.

Software assumptions: 1. Well documented system overview and specs available for each existing system. Current subject matter expert (SME) available for consultation. 2. Hardware and networking infrastructure is complete for OpenVista CIS and InterSystems Cache. 3. Hardware/Network SMEs available for consultation. 4. IT will use Industry standards/methodology (PDSA) 5. Well documented system overview and specs available for each new s ystem. 6. Vendor tech support available for consultation. 7. Business Requirements approved and signed off. 8. Clinical Re-Design Specs approved and signed off. 9. Technical expertise available via vendor support and/or outside consultants. 10. Selected software systems are compliant with healthcare industry standards and certified. 11. Current workflow & output product clearly defined for PECS, UDS Reporting and San Diego Immunization Registry.

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12. Test environment available for existing systems. Technical expertise available via vendor support and/or outside consultants. Current SMEs available. 13. User acceptance testing (UAT) environment available. Users prepared data and are available to test. 14. HIE/NHIN Gateway test environment available. HIE tech support available for testing. 15. Current systems already have established change management policy in place. 16. IT already adopted Information Technology Infrastructure Library (ITIL) IT service management framework 17. E&M coding will be done outside of the EHR and handle in the next phase. 18. San Diego Immunization Registry - San Diego County's Public Health Information System (PHIS) is on the NHIN Health Information Exchange network. 19. Mirth Appliance/Connect is the current integration engine and will be used for the new EHR software. 20. PECS usage will roll to OpenVista CIS and be deactivated after EHR implementation. 21. UDS reporting to be discontinued one year after EHR implementation. Continue using HRSA Electronic Handbook website for submission until then. 22. First DataBank is the drug database used by PIS and it will send the drug order results back to OpenVista CIS which will then trigger alerts in case of adverse result

Integration/inte roperability Solution ­ Mirth & Health Information Exchange NHIN CONNECT Mirth is the open source integration engine used by CHC to integrate its lab (LIS), pharmacy (PIS) and radiology (RIS) information systems with its practice management system (PMS). PMS sends HL7 ADT (admission, discharge & transfer) and SIU (scheduling information unsolicited) messages to LIS, RIS, and PIS upon patient registration or scheduling changes. In return, PMS receives DFT (Detailed Financial Transaction) messages from these three ancillary systems for billing purposes. Mirth facilitates the message processing and routing to/from these systems.

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Figure 4 Data Flow Current State

Due to the migration from paper-based medical record to the OpenVista EHR System, Mirth will be modified to manage the data exchanges from OpenVista to the current health information systems. It will receive and route the ADT and SIU messages from PMS and ORU (Order Result Unsolicited) result messages from RIS, LIS and PIS to OpenVista. OpenVista will in turn send out DFT messages to PMS for billing charges and ORM (Order Message) to RIS, LIS and PIS.

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Figure 5 Data Flow Future State

In addition, Mirth will also be utilized to securely connect to the Health Information Exchange (HIE) to share health data with outside providers, patients and other healthcare organizations on the Nationwide Health Information Network. The Mirth Appliance has a built in adapter layer to the NHIN Connect via its interface/channel architecture to communicate directly with NHIN Gateway without having to add an additional protocol. Linking the Community Health Center to the HIE network allows the clinic to advance the patient-centered care model defined by the Institute of Medicine. Health agencies and providers can coordinate care like tracking immunization records with San Diego Regional Immunization Registry. Implementation Strategy Continuous process improvement methodology of Plan Do Study Act (PDSA) will be used as part of the iterative software development life cycle processes. The development team will collaborate with key users to plan the change, test it, observe/study the results and act to keep or adjust the change. The PDSA cycle will guide SDLC development process as follows: Plan- Analysis/Design

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Review current system architecture, analyze new system components to be installed, analyze software requirements and clinical re-design specifications, perform gap analysis, and design custom development requirements. Do ­ Coding/Testing Configure and execute customization per design specifications on a small scale by logical work unit or functionality of the system. Immediately test changes with users to work toward the plan and design Mirth configuration changes: 1) Add OpenVista/Cache DB destination connector types to the ADT outbound channel from PMS 2) Add OpenVista/Cache DB destination connector types to the SIU outbound channel from PMS 3) Add OpenVista/Cache DB source connector types to the DFT inbound channel to PMS 4) Create new inbound channel for ORM orders from OpenVista/Cache DB source connector types to LIS, RIS and PIS connector types 5) Create new outbound channel for ORU results from LIS, RIS and PIS source connector types to OpenVista/Cache DB destination connector type 6) Create new outbound channel for VXU immunization data for SDIR from OpenVista/Cache DB source destination type and NHIN Connect Gateway destination type 7) Create outbound CCR/CCD channel using XML message format for the patient web portal with OpenVista/Cache DB source destination type and NHIN Connect Gateway destination type Other Mirth-related development tasks: Install Cache Database JDBC driver for the Mirth database reader. Configure NHIN gateway connector on the Mirth Appliance using the UDDI registr y to locate San Diego Health and Human Services Agency for SDIR data transmission Create CHC Health Information Exchange on NHIN gateway and establish Mirth Channel. Create/load test data for HL7 testing activities. Execute unit testing in the beginning iterations of PDSA cycle, make improvements until changes are ready for integration, UAT, and regression testing. Study ­ UAT/Validate/Peer Review Study and validate the test results to ensure changes made met the requirements and quality expectations. Work with users to identify issues/concerns and plan accordingly. Perform QA/peer review of the final work product before attempting the next iteration. Act ­ Implement/Support After testing and refining each unit of work on the system through the PDSA cycle, implement the change in steps. Implement OpenVista first, integrate it with Mirth and PMS, LIS, RIS and PIS. Then deploy Mirth changes with NHIN Connect Gateway to the SDIR. Support and continue process improvements.

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3.6

Clinical Work flows Post EHR

Adult Patient Visit with Appointme nt Situation CHC will deploy the OpenVista systems for its network of three ambulatory care centers and a mobile medical unit. The desire to improve patient care, reduce medical errors, increase organizational efficiency and meet federal meaningful use incentives are factors leading to the adoption. The OpenVista Clinical Information System, (CIS), component will implement electronic medical records for clinical care and operations. Key expectations from implementation are: Insuring seamless interoperability between OpenVista, the current LIS, RIS, Pharmacy IS system and the PMS to improve the quality and the speed of information and data available for patient care. Enhancement of the capabilities of document and record management through interface with the current Patient Management System (PMS). Implementation of Computerized Provider Order Entry (CPOE) and adoption of decision support tools and alerts for patient care. Improved reporting capabilities and utilization of preventive care statistics and incorporating PECS reporting system via an NHIN and CONNECT portal. Compliance with HIPAA Security Measures.

Solutions OpenVista implementation will provide a comprehensive electronic health record (EHR), system enabling clinicians to accurately and efficiently capture clinical encounters. The general implementation plan is to:

Integrate the EHR functionality with the Patient Management System (PMS) to fully automate the end-to-end process, from patient registry through patient care and medical records, through billing and receipt of payment. Implement OpenVista suite of workflows and structured tools to provide better managed care from providers, by including worksheets, alerts and best clinical practices within the workflow design. Establish Clinical teams consisting of representatives from each medical specialty and administration to perform analysis and define requirements in regards to the various workflows/operations within the three clinics. They will represent the "voice" of the entire clinical team. Perform Workflow/Operational Analysis on clinical practices and operations. 1. Review OpenVista components and functionality: Computerized Provider Order Entry (CPOE), Patient Summary, Orders Communication, Clinical Alerts and Reminders, Results Reporting, Consultation Tracking/Vital Signs, Clinical Documentation and Image Viewer, Adverse Drug Reaction Tracking 2. Define/document current workflow 3. Identify gaps between "ideal" workflow and OpenVista functionality.

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Define ideal workflows for clinical operations Document desired functionalities and specifications for the new EHR. Define Hardware requirements within the clinical operations incorporating tools to improve efficiency and quality delivery for patient care. Training for Clinical Personnel will be defined and managed by our training team with input from the clinical representatives. The Plan Do Check Act (PDCA) philosophy will be utilized between phases and throughout the implementation. Meetings will be held to review issues, lessons learned and improvements to apply for the scheduled clinic introduction. Issues will be resolved and new requirements implemented based on rating factors that consider cost/benefit and intangible value to the organization. Some may be scheduled for the future phase of implementation.

4. 5.

Challenges The challenges of implementation can be categorized as financial, organizational/behavioral or technical. A financial budget was approved for the OpenVista implementation. In addition, the HW, SW and resources required to support the information system must also be defined and cost justified. The provider use and acceptance of the EHR system is an important factor in the success of the implementation. Therefore, it is necessary to involve key personnel in defining the workflows, system reminder/alerts, and clinical guidelines and focus on the value of these tools for good patient care. Factors to consider in overcoming these behavioral challenges are to a) design the system with well integrated workflows, b) allow time to learn the details of the system, and c) provide continued training and support. Integrating the clinics various systems; RIS, LIS, Pharma IS PMS and PHR is an internal challenge. An additional challenge is developing interfaces using vocabularies, standards and databases to provide interoperability with the Health Information Exchange, (HIE).

Benefits Studies over the past thirty years have demonstrated the value of using EHR and other types of clinical information systems and similar benefits are expected at CHC: Improved Quality, Outcomes and Patient Safety. 1. Improved medication resolution and subsequent reduction in medication errors. 2. Automate consistency in best practices clinical management of common diseases by using reminders. Improved Efficiency, Productivity and Cost reduction 1. Faster and consistent communication across departments: 2. Elimination of lost charts and reduced time spent clarifying orders and documentation 3. 100 percent physician utilization of computerized physician order entry (CPOE), contributing to meaningful use compliance.

The EHR implementation is also expected to assist in collection of clinical data and for nonclinical uses such as billing, quality management, outcomes reporting, and resource planning. The OpenVista implementation will be evaluated and monitored for improved service and

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satisfaction through patient survey, employee survey and analysis of performance data of clinical procedures and outcomes. Process/Approach: Work-flow: Refer to the Pre- and Post EHR Implementation Workflow Chart in the Appendix. Assumptions: 1. Total patient visits per year between all clinics is 145,770, and 12,147 patients per month total, 21.5 clinic days/month, approx. 560 patients total per day, and central clinic sees twice as many patients as East and West, so therefore: a. Central Clinic - 280 patients per day b. East Clinic - 140 patients per day c. West Clinic - 140 patients per day 2. There are 21.5 clinic days per month. 3. The clinics combined see approximately 45,000 unique patients per year (145,770 visits total per year, but some of those visits are the same patient coming in for more than one visit). 4. Number of rooms per pod calculated based on assumption of 2.5 rooms per provider a. Central: 3 providers per pod. 6 pods. 18 providers. b. East: 3 pods. 9 providers c. West: 3 pods. 9 providers d. Mobile: 1, Floaters: 2 5. Total patients per day in all clinics combined are 560. Total providers per day in all clinics combined are 36, so each provider sees approximately 15.5 patients per day. Assuming a 40 hour work week per provider and 8 hour days/5 days per week; 480 minutes per day divided 15.5 patients averages to 30 minutes per patient (we are allowing 15 minutes for follow up appointment, 30 min for a pelvic exam, 45 min for a complete physical, and 10 minutes per hour is spent by provider answering phone calls, consulting with specialist, and reviewing labs) 6. During go- live, we will reduce the number of patients scheduled as below: a. Week 1 of Go-Live: Each provider sees 8 patients per day and therefore has 60 minutes per patient. (480 minutes divided by 7.75) b. Week 2 of Go-Live: Each provider sees 11 patients per day and therefore has 45 minutes per patient. (480 minutes divided by 11) c. Week 3 back to regular scheduling as above. 7. PSR time per patient = 5 minutes a. Central Clinic with 280 patients/day translates to: 23.3 hours per day of PSR, which calculates to 3 FTE, but we need, 4 FTEs on duty at one time to cover breaks, special requests, miscellaneous, with 3 sitting at desk, with one on mobile unit. Mobile unit is headquartered at Central. One FTE PSR and one FTE provider. b. East Clinic with 140 patients/day translates to: 11.7 hours per day of PSR, which calculates to 1.5 FTE, but we need: 2 FTEs on duty at one time to cover breaks, special requests, miscellaneous c. West Clinic with 140 patients/day translates to: 11.7 hours per day of PSR, which

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calculates to 1.5 FTE, but we need: 2 FTEs on duty at one time to cover breaks, special requests, miscellaneous. 8. Mobile Clinic One provider from central and one PSR from central will staff mobile clinic Will be out 3 days, 8 hours each day, total 24 hours/week Services provided: i) Immunizations, ii) School physicals, iii) Screening for obesity, diabetes, etc. 9. After EHR implementation, patient can log into the patient portal and update their demographics and general information, either at the clinic or from home. Patient will complete paper or computerized patient satisfaction survey at kiosk in clinic at end of visit. 10. Sample medications will be handled by the pharmacy because they already have a system in place to log and control medications. 11. Dieticians, case managers, and all ancillary staff will be using EHR system. 12. An electronic copy (via CD/DVD) of patient's health information will be provided to patients who request an electronic copy of their health information. A clinical summary of the patient's office visit will be provided to patient for all office visits. The after-visit clinical summary will contain an updated medication list, laboratory and other diagno stic test orders, procedures and other instructions based on clinical discussions that took place during the office visit. The clinical summary will be provided through printed copy and the patient portal.

Billing Workflow Situation Network of three ambulatory care centers and one mobile medical unit are deploying OpenVistA electronic medical record (EHR) system. The clinics provide adult, obstetrics and pediatric health care. There are pharmacy, radiology and laboratory services with their informatio n systems in place. Community Clinic currently employs a Practice Management System (PMS) for registration and billing services. A super- user will be identified and trained to develop workflow re-design for incorporating all information systems and the new OpenVistA EHR system. Goals

Seamless interoperability between OpenVistA, the current Laboratory, Radiology and Pharmacy IS systems and the PMS. Maximizing charge capture aided by an Evaluation and Management (E&M) calculator Converting from a paper superbill to an electronic superbill without overwhelming the providers Solutions

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Maintain current personnel and train in new workflow and EHR system as it integrates with current PMS. Ensure that all configured information in EHR is from discrete data sources including LOINC, CPT, ICD-9 CM and SNOMED CT to facilitate E&M calculations. Continue importing all charges from the LIS, RIS and Pharmacy IS into the PMS and add on the diagnoses and CPT codes from the EHR to process charges for visits.

Benefits

Improved charge capture and maximized revenues Improved turnaround time for sending out billing charges Improved documentation of patient encounter; information readily available to substantiate all charges and audits Reduced workload when responding to insurance companies for more clinical information

Assumptions

Interoperability between existing Laboratory, Radiology and Pharmacy IS and PMS is well established and meets HIPAA requirements Pre EHR, each department has an existing customizable paper superbill with most common CPT and ICD-9 CM codes ready for easy check off. E&M codes list as per clinic and specialty; at level of Billing Department Mobile clinic has PC on board that connects via secure wireless internet connection to central server Scanner present at Front Desk for scanning ID and insurance cards Centralized scheduling across all locations and physicians; real time Billing personnel are given HIPAA privacy privileges to view but not modify clinical notes Billing aspect of PMS centralized Billing work-flow

Process/Approach:

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Workflow - with EHR Practice Management System (PMS) in Place

Billing Workflow & Medical Records/Abstracting

Abstracted Chart sent to PSR at Clinic.

PSR performs tasks in PMS: - Convert master ID to a patient Medical record #. - Updates, Collects Deposit/Co-Pay & payer information. Posts in PMS - Scans ID & insurance card.

Add Pt name to "To be scanned" Worklog

MR abstractor locates Record, scans, & abstracts for NEXT DAY Patients.

Medical Records

- Patient records verified complete/approved. - Chart sent to long term storage.

PMS is utilized. - PSR schedules an appoint. - Demographics & Insurance info input into PMS

PSR

- List of Patients for next day is generated.

· PSR Logs into PMS to review daily schedule. · EHR automatically populated with schedule information.

Patient checks in with PSR to verify Insurance or self-pay. If Self pay referred to social workers, etc. for Financial assistance.

Patient

Patient is processed as per Adult patient Work-flow sheet.

Toward end of Patient encounter.

Using CPOE : - Orders & procedures are entered for auto processing into PMS - E&M calculator suggests OV level

Chart reviewed for accuracy of codes & Documentation.

Review & approves Abstracted & Scanned items Signs off paper chart Chart sent to Medical Records

PROVIDER

NURSE

Completes & confirms all provider orders then Flags orders as completed in EHR

BILLING

- Bill generated & checked for accuracy - Electronically submitted to insurance or patient

NO Bill paid?

· EOB scrutinized & if necessary chart is electronically pulled, notes sent electronically. Bill resubmitted or adjusted

YES

Bill reconciled A/R adjusted. - End

Lab, Rad Pharm

Code for billing & diagnosis from the PIS, RIS & Pharmacy auto migrates to PMS

40

Step 1: Scheduling Department Via phone: New patient: Appointment scheduled. Demographics/insurance information obtained and entered into PMS software. Determine if referral or pre-authorization is necessary and, if so, has it been obtained. Established patient : Appointment scheduled. Recheck/update demographics and insurance information. Via Patient Portal: Established patient may schedule appointment here. Patient can access and update all demographic and insurance information. If established patient not in EHR database, Chart Room notified of need to scan and abstract patient's records.

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Step 2: Front Desk Patient shows up for appointment. Encounter opened. Via Front Desk: New patient: Create patient MR number and verify insurance Established patient : Recheck information and confirm accuracy Via Patient Kiosk: Patient may opt to access Patient Portal at Patient Kiosk PC for same. If returning patient arrives without appointment and not in EHR database, Chart Room notified of need to scan and abstract patient's records Collect co-pay and post in PMS (if applicable) Patient photo scanned into EHR PMS alerts Mirth Connect of changes to data. EHR and other ancillary databases updated as necessary.

Step 3: Patient goes through visit as depicted in Adult Workflow Sheet Provider records clinical data into OpenVista. The orange file symbols indicates paper printed mainly for client information. (Note: most orange symbols no longer exist)

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Step 4: Providers As provider completes computerized physician order entry (CPOE), all ICD-9 CM and CPT codes associated with appropriate diagnosis(es) and procedure(s) performed auto-populate into PMS for bill processing. E&M calculator identifies the level of service and suggests appropriate office visit level charge code to provider. Provider can accept or override code but an alert will suggest what changes need documentation to justify level of care. Confirmed level of care populates PMS for that office visit. Step 5: Laboratory, Radiology and Pharmacy After Patient Encounter, appropriate charges migrate to PMS and charges generated. Step 6: Billing Department Billing personnel review electronically- generated bill for accuracy, then send electronically to payer(s).

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Wait for payment and reconcile the Explanation of Benefits (EOB) and Accounts Receivable (A/R) using PMS. Step 7: Patient Patient may view any charges on line at any time and make payments via Patient Portal. Patient can also update demographics.

3.7

Clinical Decision Support Tools

SUPPORT TOOLS IN OB/GYN DEPARTMENT

Using Perinatal Care Guidelines, Based On American Academy Of Pediatrics & American College Of Obstetricians And Gynecologists, 2007 INITIAL PRENATAL VISIT History & Physical Exam: TEMPLATE Pre-Existing Condition: ASSESSMENT ALERT THAT LEADS TO ADDITIONAL TEMPLATE 1 ST AND 2 ND TRIMESTER Blood Pressure: REFERENCE RANGE INFO Weight and Fundal Height: CALCULATIONS Fetal Heart Rate: REFERENCE RANGE INFO Interim History, Fetal Movement, Contractions, Vaginal Bleeding, Fluid leakage: FLOWSHEET If overdue for visit per guidelines: ALERTS Urine screen: FLOWSHEET At specific weeks of gestation for tests as indicated, e.g. Diabetes Screen at 26-28 wks: REMINDERS Gestational Age and abnormal test results: ALGORITHMS 3 RD TRIMESTER Blood Pressure: REFERENCE RANGE INFO Weight and Fundal Height: CALCULATIONS Fetal Heart Rate: REFERENCE RANGE INFO Interim History, Fetal Movement, Contractions, Vaginal Bleeding, Fluid leakage: FLOWSHEET If overdue for visit per guidelines: ALERTS Urine screen: FLOWSHEET At specific weeks of gestation for tests as indicated, e.g. GBS Screen at 35-37 wks: REMINDERS Gestational Age and abnormal test results: ALGORITHMS POSTPARTUM VISIT Blood Pressure: REFERENCE RANGE INFO Weight: CALCULATIONS Breast, abdomen, and pelvic exams: TEMPLATE Physical Exam & Interim History: TEMPLATE

Labs: LAB/DIAGNOSTIC TOOLS ORDER SET for all labs

Pap Smear, Birth Control, tests as indicated: REMINDERS

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Nutrition and Prenatal Care:

EDUCATION/ COUNSELING

Signs/symptoms premature labor, med use, exercise, nutrition, avoid smoking and substance abuse, car safety belts, monitoring fetal activity, when to call provider: CARE PLANS PRINTED EDUCATIONAL MATERIALS AND INSTRUCTIONS

CARE PLANS PRINTED EDUCATIONAL MATERIALS AND INSTRUCTIONS

Signs/symptoms labor and pregnancy induced hypertension; exercise, nutrition, avoid smoking and substance abuse, infant care, breast or bottle feeding, monitoring fetal activity, when to call provider: CARE PLANS PRINTED EDUCATIONAL MATERIALS AND INSTRUCTIONS

Birth control, breastfeeding and mastitis, postpartum depression, restrictions and limitations, exercise & nutrition, when to call provider:

CARE PLANS PRINTED EDUCATIONAL MATERIALS AND INSTRUCTIONS

BUSINESS RULES, REMINDERS AND ALERTS Why Business Rules, Reminder and Alerts? Business rules will provide consistency and control over the clinical process. The reminder and alert utilities of OpenVista will improve the compliance of patient safety and efficiency of the medical providers' workflow. Challenges Creating awareness of deviation from accepted practices without resulting alert fatigue with clinical staff Creating awareness of recommended health practices without resulting in reminder fatigue with patients Implementing controls within the system and processes without making clinicians feel constricted or bogged down with protocols Benefits Automation of reminders through the patient portal, mail or phone reminder to patients will improve patient self-care. Alerts on the clinical side will aid the medical provider in identifying problems, drug allergies, drug-drug interactions. Alerts can also prompt protocols. Business rules will improve quality of care and patient safety. Process for Reminders Providers can work with their local Clinical Coordinators to set up customized reminders based on local and national guidelines for the following patient education, immunizations, skin tests, measurements, exams, laboratory tests, mental health tests, radiology procedures, and other procedures. Clinicians play a role in the setup of reminders by helping to define the following:

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· Clinical reminder definitions (these definitions are used within the Health Summaries Package, the Computerized Patient Record System (CPRS) GUI, and on encounter forms) · Findings that identify whether the reminder applies to the patient, that satisfy the reminder, and that provide additional clinical information · Dialogs to resolve reminders (within CPRS GUI, you use a point-and-click interface for each reminder you want to process) The IT software programmer working with the Clinical Coordinators will define a list of possible actions related to the reminder and to create the appropriate dialog check-boxes for each reminder. Process for Alerts Implement automated, electronic clinical decision support rules according to specialty or clinical priorities. Automatically and electronically generate real- time alerts and care suggestions based upon clinical decision support rules and evidence grade. Automatically and electronically track, record, and generate reports on the number of alerts responded to by a user OpenVista allows the user to customize the alerts to his/her comfort level or requirements. Process: for Reminders (1) Real-time alerts for abnormal test and lab results, drug-drug and drug-allergy contraindications; (2) Electronically check if drugs are in a formulary or preferred drug list; (3) Provide certain users rights to deactivate, modify, and add rules for drug-drug and drug-allergy checking; (4) Track number of alerts users respond to. The latter will allow QA to monitor compliance with alerts Alert provider of weight and height disparity Remind provider to counsel patient on smoking cessation when appropriate Send alert to provider on abnormal results. Sent alerts on critically abnormal results that require immediate action Electronically generate a patient reminder list for preventive or follow- up care

TEMPLATE AND FLOWSHEET PROCESS Why templates and flowsheets? Templates will aid the provider with drop-down menus, or a series of radio button options with list items to quickly describe symptoms, such as the character of pain, it's location, intensity, duration and describe the choices of data that could be entered for each item. For example, in the CPOE, the template may be a list of common orders for a certain diagnosis (see attached Postappointment Order Sheet). Flowsheets help to speed up certain clinical encounters and are designed to be easy to follow. (See attached Diabetes flowsheet). Flowsheets have the added functionality of converting the data into graph form to easily see trends and to share information with patients. An example would be a graph of cholesterol results over time.

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Challenge

To establish procedures and protocols for the design and implementation of templa tes and flow charts in the Open VistA EHR environment. To make the workflow re-design move smoothly by take familiar paper templates and flowsheets and incorporating them as much as possible into the EHR

Benefits

Improve patient care Clinical decision support tools within templates. Automate consistency in best practices clinical management of common diseases by configuring the templates with best practice protocols along with reminders and alerts Healthcare cost savings by avoiding inappropriate tests or ineffective medications Implementing information standards for system interoperability (exchanging and processing data between systems) Decrease time needed for data entry, save time and provide access to the best quality clinical tools and links to supporting material such as protocols, teaching resources, and audit tools

Process Currently each department has a file cabinet with preferred encounter forms and flowsheets organized by provider preference. At the time of the medical encounter the paper medical record is prepared with the anticipated forms required for the visit. The provider may secondarily add or subtract form from his/her file and place them into the chart. (See attached example o f a well women encounter form). Step 1. All healthcare provider stakeholders departments will be asked to gather and organize currently used templates, encounter forms and flowsheets. All forms should be reviewed and updated to comply with best practices

Initially, each department (Women, Pediatrics and Ad ult) will submit forms for wellness visit and common acute care encounter forms. Examples: Well Woman, Prenatal flowsheet, Acute otitis media, Asthma follow-up

Step 2. The available templates from Medsphere and or independent collaborators will be reviewed for adoption. Step 3. In coordination with the medical providers, Quality Assurance department and the Software/vendor IT personnel templates and flowsheets will be created utilizing discrete data from the knowledge databases (SNOMED-CT, ICD-9, CPT, LOINC). Strict adherence to using discrete data will facilitate data mining, E&M calculation software, and interoperability with the existing systems. Step 4. Templates and flowsheets can be created for history taking, physical exam, orders, and lab results tracking

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Step 5. All templates and flowsheets must have final approval by the department head before being utilized in the EHR. This is to ensure that discrete data was used and that best practice protocols are followed. Assumptions

Existing templates provided by vendor or independent collaborators will be utilized as much as is possible in the interest of not reinventing a tried and true process. (www.clinicaltemplates.org). An open Source portal for various projects working on the collaborative development and sharing of clinical templates and supporting documentation). Clinical collaboration and consensus is essential to make information standards usable and useful:

it can simplify the inputs to the modeling process and assure quality it encourages adoption and use of the approved templates All providers will be given group and one-on-one training on how to create or modify their own templates and flowsheets. Utilize the PCDA process to ensure a continuous improvement process.

EXAMPLES OF TEMPLATES AND FLOWSHEETS

ADULT TEMPLATES

Urinary Tract Infection Diabetes Hypertension COPD/Asthma Hypercholesterolemia Obesity Depression Screening

WOMENS

Initial History & Physical Exam Diabetes Hypertension COPD/Asthma Hypercholesterolemia Obesity Urinary Tract Infection 1st Trimester Assessments 2nd Trimester Assessments 3rd Trimester Assessments Postpartum: Breast exam Postpartum: Abdominal exam Postpartum: Pelvic exam Postpartum: Physical Exam & Interim

PEDIATRICS

Upper Respiratory Infection Urinary Tract Infection Asthma Obesity Diabetes Preventive Health

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History

FLOWSHEETS

Diabetes Hypertension COPD/Asthma Hypercholesterolemia Obesity

Prenatal: blood pressure, weight, fundal height, fetal heart rate, interim history, fetal movement, contractions, vaginal bleeding, fluid leakage Preventive Care Services: mammogram, pap smears, cholesterol, weight loss or maintenance

Age-Specific Flowsheets: (e.g. 01 year, 1-3 years, 35 years, etc.): Body measurements, Immunizations, and Developmental Milestones

1- Post-App ointment Order Sheet ( Please see appendix) 2- Diabetes Flow Sheet (Please see appendix) 3- 8_Well_Wome n_Visit_encounter_form (Please see appendix) 4- 12_psq18_s urvey_RandHealth

3.8

Training

Training must be intuitive. By being intuitive the clinic will realize greater productivity ­ thus higher revenues. Training also follows workflow, be that guiding a patient from one point to the next; processing a prescription, or ordering tests. Training Metrics Level 1 Measures the staff's reaction to the EHR implementation and gaining knowledge of the overall system. In this level, all staff in all clinics will attend a kick-off meeting and participate in the EHR implementation survey. This will be followed 7 days prior to kick off, with a quality control survey. Measures mastery of the tasks and information of the EHR system through classroom training, and on- line practice. In this level, all end users and auxiliary staff will be trained at each rollout clinic.

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Level 2

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Level 3

Measures as an expert of the EHR system. In this level, the super user trainers will be trained at the off-site by the vendor. They will have a clear understanding of the system, both in theory and in the real world. They will train staff at the staff work area.

Personnel Train the trainer Physician RPN Nurses PSR Admin LIS Pharmacy IS RIS Total

Central 1 8 10 18 3 33 10 8 10 100

East 1 4 5 9 2 14 4 4 5 47

West 1 4 5 9 2 14 4 4 5 47

Mobile

Floater

1 1

2 2

2

4

Total 3 16 23 38 8 61 18 16 20 203

PSR: Patient Service Rep LIS: Laboratory Information System PIS: Pharmacy Information System RIS: Radiology Information System

Beyond those 3 levels, CHC will create on-going training program and new user training. Online training will be available during roll out, and for the life of this system. Training strategies CHC strongly believes the training program would prepare the CHC team to embrace the new EHR implementation, minimize challenges during this transition, foster successful change, and improve performance through: People Process Technology Change management approach to create EHR ownership by staff at all levels Systematic approach using process improvement methods Proper use of EHR functions to help staff perform their work effectively

The training program is a comprehensive training plan including support, and communications. It is a multi-phase approach, and follows the Plan, Do, Check, and Act (PDCA) cycles to generate lessons learned for the next clinic implementation. Points of consideration Central clinic is the largest clinic with two pods, complete administration offices, and main Lab, Pharmacy, and Radiology dept. It is chosen to be the first clinic to rollout due to the full support staff availability.

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Staff is trained in classroom, as well as hands-on (mock training) task sessions tailored to staff responsibilities. The quick reference cards, cheat sheets, and diagram of work flows are available at work site. Use newsletters and email to address EHR implementation; post EHR progress in break rooms, and discuss EHR information in regular staff meetings. Nurses and clerical staff need to be comfortable with system documentatio n, security procedures, navigation results, clinical retrieval, and order entry prior to provider use. Train auxiliary staff and ensure that they are familiar with orders entry and resolving transmittal issues. Offer a primary training day and then a make-up training day to ensure all staff are trained. Have one bound hard copy of the training manual for reference at each clinic. Once per month, for the first 5 months, offer rewards to those who discover, and document well, short cuts and other useful tools of the system. Set up Help desk and provide on-site support. When going- live: Pick a light day: weekend, night shift, or mid week based on clinic history. Consider reducing provider schedule. Allow time during the day for provider to catch-up (mid morning or mid afternoon buffers). Ensure sufficient resources available (additional IT personnel, 1:1 support ratio for provider). Inform admin, lab, pharmacy, and radiology staff for additional support while going- live Plan for what to do if things really go wrong: when to stop EHR implementation and go back to the paper process. Schedule end-of-the-day to debrief and to identify problems and address issues.

Post going- live: Resolve EHR issues and adjust/ clarify/ simplify training accordingly

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3.9

Configuration Management Plan

Situation CHC has received a federal grant to install an Electronic Medical Record (EHR) system that allows the healthcare center to meet the Meaningful Use. For information assurance, Configuration Management is set-up to control of changes made to hardware, software, firmware, documentation, and test documentation throughout the life cycle of the newly installed EHR system. Solutions The Configuration Management of the EHR system contains components of: Configuration Identification Change Management Configuration Status Accounting Configuration Audits

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Benefits Minimize the impact of changes from current paper charts, a largely manual process of compiling, updating, and accessing paper-based patient charts, to the EHR system Provides accurate information on Configuration Items (CI) and their documentation Control document scanning protocol at Central clinic. Central scanning is used for documents that we receive from outside our system in paper form. Point o f care scanning is used for a myriad of documents such as consent forms, Medicaid cards, home blood pressure logs, etc Make software changes visible: common visit templates, particularly for well-child visits and prenatal visits. Improves security by controlling the versions of CIs in use Supporting and improving Release Management Adherence to legal obligations: Meaningful Use, HIPAA, patient care guidelines, etc... Helps in financial and expenditure planning: reduces the use of un-authorized software Allow the CHC to perform impact analysis, contingency planning, problem management with data and trends

Process/Approach Track new, changes, and process obsolete documents stored in the Configuration Management Database (CMDB) and the Definitive Software Library (DSL) Utilize Microsoft Team Foundation Server 2010 for Application Lifecycle Management for version controlled document library for Definitive Software Library (DSL) Control physical configuration, updating of, and integrity of all software development, testing, training, and supporting environments Establish and enforce Configuration Management processes and procedures necessary to facilitate and control access, updating, back-up, disaster recovery, and configuration of these environments in conjunction with technical support personnel Ensure synchronization between environments is maintained at all times Control builds and installations in the environments Provide critical data to effective and efficient Incident, Problem, Change and Release Mgt Verify system configurations against stored configurations and correct discrepancies.

Downtime Plan

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Situation The Community Health Connects (CHC) needs access to forms and patient health information at a moment's notice. This downtime plan is created to keep the EHR clinical data operational and helps healthcare providers and clinic personnel deal with the unexpected and deliver uninterrupted patient care. Downtime may affect a single application or may be system wide. There are two types of downtime: Scheduled downtime is planned in advance for reasons including scheduled maintenance, system updates and patches, and upgrades. It can be daily, monthly, or quarterly basis. Unscheduled downtime is due to system or environmental failures such as power outages, earthquake, etc. Solutions A committee with representation from every clinical department using the computer system met to develop the downtime plan.

Benefits Minimized chaos, frustration, and confusion when the EHR system is down Reduced errors in documentation. Ensures timeliness oftransfering clinical documents and accurate charges. Coding is updated after the EHR system back on- line.

Process/Approach Communication plan Scheduled downtime: Send an initial and a reminder email with the p lanned downtime date and time to all physicians, providers, clinical staff, senior leadership, management, and IT staff. On the evening of a scheduled downtime, announce on the PA speaker system to remind staff of downtime. Use Downtime Communication template: what, when, how long, why the EHR system is down. Unscheduled downtime: Announce in the PA speaker system to notify staff of downtime.

Procedure of downtime Print out schedule for those hours that system is down. Make available blank encounter forms and charge slips and write patient information by hand or pre-printed labels. For patients without a pre-scheduled appointment, assign a temporary medical record number. Initiate a manual process for patient phone calls. Upon notification that the system is back up, a designated person will schedule and check- in those patients who entered the practice during downtime (in chronological

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order). Retrieve encounter forms or charge sheets and enter charges into the system in a batch day-by-day process. Clinical Documentation For Labs and Radiology department: testing results require printing out results prior to a planned downtime. Results may be faxed to a satellite practice or communicated by phone for urgent matters. Otherwise, all results will be printed and placed on a temporary downtime patient record Allergy information must be included on these paper-based forms to ensure that this vital health information is not lost during downtime. All medications given or ordered during downtime would be documented on the form specified in the downtime plan Providers that use e prescribing will need to write out prescriptions on paper pads to give to the patient, or when permitted, these prescriptions may be telephoned into the appropriate pharmacy. Some prescriptions may require tamper-proof prescription pads.

-

-

Special projects Provider should develop a list of the programs and projects in which it participates. This inventory should include the required queries and responses that meet the program requirements such as Physician Quality Reporting Initiative, patient-centered medical home pilots, health district requirements (such as immunizations and vaccinations), and federal or state registries.

Charge capture and coding Staff should code these paper-based charge slips completely with the appropriate CPT, HCPCS, and ICD-9-CM codes. They should complete links between the services performed (CPT and HCPCS codes) and the reasons the services were performed (ICD-9-CM codes). Necessary modifiers should also be appended to the appropriate CPT or HCPCS codes. Although this process will be completed manually, it should be completed during the actual downtime. This will expedite the charge entry process once systems are operational.

Bring the system back on-line Create a checklist using the expertise of the IT department along with the day-to-day knowledge of the key players within the practice.

Training and downtime drills All system users should have regular training on downtime procedures. Schedule drills on a regular basis to prepare for system downtime.

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3.10 Patient Portal

A patient portal will empower the clinic patients by providing direct access to the clinic, their medical providers and focused access to their patient record from any computer in the world. The clinic's patient portal will incorporate the following functionality:

Web-based Accessible at the patient's home or office computer, or mobile device, with just a username and password Patient can Opt-in or Opt-out of who can see their information within the NHIN Intake forms (Demographic information integration) Appointment requests Reminders for preventive health care (Pap smear, annual exam) Track health goals See current medications Messaging to doctor(s) and staff Lab results Prescription refill requests Full EHR software integration Also regular smoking cessation alerts will help meet Meaningful Use requirements and other patient directed educational tips/instructions Providers can send messages such as appointment reminders, electronic statements, and lab results to patients

Challenges

Security Adoption Usage ­ people who don't normally use computers (older generation) or situations where families can't afford their own access, will inconvenience (of going to libraries or to the clinic) slow the adoption and usage rate?

Benefits Improved patient satisfaction and Improved patient care Improved communication and meet Meaningful Use mandates

Assumptions Data is exchanged in a HIPAA (Health Insurance Portability and Accountability Act) (www.hipaa.org) compliant and secure fashion. The patient's data is encrypted. The practice can be sure that HIPAA standards are being met. The Patient Portal should have English & Spanish versions Physicians adopting EHR begin to realize the potential benefits of a Patient Portal. The practice is the ultimate authority regarding how much data is conveyed to the patient. The patient can log on to a HIPAA compliant and secure web site and patient fills out the intake forms in their own home. For patients that do not have access to an internetImplementation Plan Copyright © 2010 UCSD Extensions HIT Spring 2010 Class Page 73 of 100

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enabled computer, a HIPAA compliant touch screen kiosk with a PC will be available in the lobby away from wandering eyes.

4 Monitoring and Controlling

Data will be collected and reviewed periodically throughout the duration of the project. The data to be collected will include the necessary tracking information to be able to report on meaningful use, financial return on investment, quality measures tracking, compliance metrics and patient satisfaction surveys. This data will also be available later for CHC to use to qualify for a higher level of patient care payments based on provable patient outcomes. Following the implementation of the plan we will review the status and discuss any outstanding issues. We will also make sure that our new systems have the proper maintenance and support contracts in place to assure our system reliability.

5 Closing/User Acceptance Testing

Situation User acceptance testing will be performed to verify that the total system. User acceptance testing will comprise the following tests: Software/Hardware Testing: Test software extensively before implementation. Set up a test database for software testing and for staff training. Thoroughly and completely test all areas of the software and utilize the end-users to test their specific functions. Perform Volume testing. Take a typical day and do a dry run in a test database. This step is often overlooked but can provide important information regarding the time it takes to enter data with typical volume or increased volume. Ask for a list of known bugs from the vendor for the version you are about to install. If bugs exist, ask the vendor to create work-arounds and identify dates for patch fixes. We want to identify system flaws or bug during the testing phase when they can be calmly addressed and fixed.

The above three categories address the testing of the OpenVista EHR system. We are testing our implementation of the software, selected clinical templates, and end-to-end functionality. Solutions ( What is the end intent of the process) UAT will verify that both software deliverables and associated non-software deliverables (documentation, forms, procedures, etc.), will function successfully together in the business environment and will fulfill user expectations as defined in the business requirements and functional specifications. User acceptance and comfort with the overall functionality o f the EHR. User acceptance and comfort with the functionally of interoperability between LIS, RIS, Pharmacy IS, and PMS. User acceptance and comfort with the functionality of implemented clinical templates. UAT will support the readiness to Go-Live.

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Challenges In the view of many experts, UAT is the single most important stage in the software development process, the last chance to ensure software is fit for purpose before releasing it for widespread use.

UAT is one of the most difficult stages to manage and often, one of the least appreciated by Senior Management. Buy in by Senior Management up front is essential to build a successful UAT team. UAT should confirm whether the software supports the existing business process, not just whether or not the software works. Any user requirements that may evolve during UAT should be part of a later release to stay on the timeline. Failure to conduct UAT will result in problems being found after release.

Benefits (How will the clinic, community stakeholde rs or patie nt benefit) UAT will reinforce CHC community involvement with the project (not just an IT project.) UAT process will gain the (positive) reputation of the super-users. UAT process will validate the security of the EHR. UAT process will keep project on scheduled timeline. UAT will reduce the rsik of time consuming and expensive bug fixes. UAT will catch errors and assumptions that are not caught in other types of tests and planning. UAT will compare user expectation to actual results early in the implementa tion process. Super- user acceptance will influence user community acceptance of the EHR. User acceptance testing will inform and positively influence the EHR training environment. Process/Approach: (outline the process, what has to be done) This acceptance tests will be carried out by the Super-Users Process Acceptance Testing group located at the Central Clinic. The following testing refers to testing the particular clinical templates and modules that CHC has selected to reproduce CHC's clinical workflows that will be implemented in the EHR. Step 1 Pilot systems before imple mentation: Pilot workflows, procedures, modules, templates, documentation time etc. in a live environment utilizing a small group of staff long before go- live. This is critical to identifying issues that are unforeseen during the planning phase. Step 2 Appoint Super-Users: Designate certain users to be "Super-Users". Their role is to provide immediate, first line response to staff with questions and issues during go-live. Designate a Super-User for each type of clinical role (MA, nurse, receptionist, provider). Super-Users should have a more extensive knowledge of the software and workflows and should be free of clinical duties so they are available all the time during the go- live period. Step 3

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Run Test Cases: Test cases completed should be marked as "closed" on the test log. This will allows the Super-Users to focus upon the still "open" for clinical templates that still need to be tested. Open cases will be addressed and technical adjustments made by the IT Department until the clinical templates are functioning properly. After adjustments are made, the still "open" clinical template will be re-tested and marked still "open" if further adjustments are needed, or "closed" if the clinical template is functioning properly. An issue is "closed" or "completed" if the performance test is passed based on critical criteria established by the Clinical team; screen loads in X seconds, Records saves in Y seconds, etc. These test cases are very much TBD. Step 4 Evaluate staff's readiness for go-live: Assess staff's knowledge of the software and workflows. Create mock live situations and walk-through the workflows considering all possible scenarios. Be prepared to delay go- live if staff is not sufficiently prepared. This is the "sign-off" portion of UAT. Step 5 Go-Live vs. Not to Go-Live: All of the clinical templates and other UAT test cases should be marked "closed" before Go Live. Once the UAT Team/Super-Users are comfortable that the EHR is functioning properly as installed, UAT should be signed-off of and the Go-Live stage can begin. It is important to understand that UAT sign off means the EHR and the selected templates are functioning as expected. Post UAT acceptance, there should be a Go-Live meeting with the Chief Medical Officer, IT Department Leader, and the Super-User. Go/No-Go should be determined at that final meeting. If all of the system specifications have been met, the EHR is performing as expected, and there is still a "No-Go" vote, then concessions must be made to facilitate the comfort of the Super-Users with the EHR. The decision to Go-Live/No-Go would probably include a UAT sign-off of the "required to golive" functionality that is TBD. Assumptions

Testing will occur in the CHC central clinic training room. The IT Department will make sure the testing hardware and software builds will be available for the testing group at the central clinical training facility. Interoperability between the existing LIS, RIS, PIS and PMS is well established. Each department has an representative super-user. Staffing adjustments will allow Super-Users to test before and after hours. The UAT testing phase is not intended to re-design clinical workflows. Clinical workflow redesign should be addressed via PDSA cycles post Go-Live after operational metrics have been collected and an appropriate amount of time has passed using the EHR.

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UAT Team and Test Case Log Sample Name(or Role) Training Leader/CMO Super-User Super-User Super-User Responsibility UAT Team Leader Test Plans, Testing Scenarios Test Execution User Acceptance Signoff

USER TESTING LOG ­ Example

Scenario

Date Tested

Procedure What are the system parameters that need to be set up? Check interoperability with PMS (accurate data into EHR.) CPOE module of EHR 1. Input expected values. Document Results. 2. Input "bad" values. Like a BP of 200/140. What should happen? An alert should trigger.

Open/ Closed

Tester/Initials

Patient Registration Physician Orders Vitals

LAB RAD Pharmacy IS Hypercholesterolemia Template

Diabetes Template Asthma/COPD Template Obesity Template

Urinary Tract Infection Template

Implementation Plan

Check interoperability with LIS (accurate data into EHR.) Check interoperability with RAD(accurate data into EHR.) Check interoperability with PIS(accurate data into EHR.) Hx of CAD should trigger an alert due to these conditions co-morbidity. This is turn should trigger a protocol or a recommended Best Clinical Practice. Hx of Edema should trigger a protocol for renal screening. Hx of tobacco smoking should trigger a protocol for patient education for smoking cessation. Family Hx of Diabetes or CAD should trigger further screening and a referral to a Dietician. Presence of Back Pain with UTI should trigger a screening for kidney infection.

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Data Migration (Paper Records Conversion)

Patient Portal Testing Disaster Recovery Security

Input/abstract paper chart data into the EHR. Test case should be checked by UAT testers prior to first patient visit post EHR implementation. Test access to the Patient Portal Opt/In-out choices for legal compliance Test disaster Recovery process Test security roles

5.1

User Acceptance Test Results

Open Issues Please insert a copy of any open issues from the Test Log, together with details of why these issues remain open at the sign off of the Acceptance Stage. Test cases completed should be marked as "closed." This will allows the Super-Users to focus upon the still "open" for clinical templates that still need to be tested. Open cases will be addressed and technical adjustments made by the IT Department until the clinical templates are functioning properly. After adjustments are made, the still "open" clinical temp late will be retested and marked still "open" if further adjustments are needed, or "closed" if the clinical template is functioning properly. Document Sign Off Who EHR Project Manager Chief Medical Officer UAT Testing Coordinator Go Live vs. Not to Go Live? All of the clinical templates and other UAT test cases should be marked "closed" before Go Live. Once the UAT Team/Super-Users are comfortable that the EHR is functioning properly as installed, UAT should be signed-off of and the Go-Live stage can begin. It is important to understand that UAT sign off means the EHR and the selected templates are functioning as expected. The UAT testing phase is not intended to re-design clinical workflows. Clinical workflow redesign should be addressed via PDSA cycles post Go-Live after operational metrics have been collected and an appropriate amount of time has passed using the EHR. Post UAT acceptance, there should be a Go-Live meeting with the Chief Medical Officer, IT Department Leader, and the Super-User. Go/No-Go should be determined at that final meeting Date

NEXT STEPS FOR EHR SUBTEAM OF CLINICAL PROCESS ANALYST TEAM

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1. We have defined the workflow pre- EHR and anticipated workflow post-EHR. We will modify the post- EHR workflow as needed after go- live. 2. The OpenVista application meets the most critical needs of our workflow process. We will assess if the application lacks in other functionality and create a gap analysis plan. We will prioritize any missing functionality and work with our technical staff to prioritize those needs and address them during future rollouts. 3. To ensure patient satisfaction with quality of care, they are currently completing the Rand Health's Patient Satisfaction Questionnaire (PSQ-18) on paper after their visit (see example attached). The survey has 18 questions and takes approximately 3-4 minutes to complete. This survey will continue to be completed by patients, but there will also be an option to complete it online at the clinic kiosks for patients to complete after their visit. (http://www.rand.org/health/surveys_tools/psq/index.html) 4. Future efforts will concentrate on improving quality of care for our patients and improving processes. A Quality Assurance (QA) department already exists and this department will continue with their normal work flow in chart audits except they will access the chart electronically instead of pulling a paper chart. The chart audits are carried out by the Quality Assurance department on a monthly basis. Twelve charts are pulled for each medical provider. Two patient charts with a diagnosis of hypertension, obesity, hypercholesterolemia, Asthma/COPD and diabetes, and 2 charts at random. The QA Team will perform metrics to track best practice protocols and business practices. Some practice protocols we will measure are: meeting hemoglobin A1C goals for diabetics, reduction in medication errors, and level of blood pressure control for hypertensive patients. Some business practices we will measure include: patient wait times, return on investment of EHR system, and percentage of physician CPOE utilization. All these measures will be compared for compliance with Meaningful Use criteria. The quality of care will be evaluated by chart audits. The EHR chart will be pulled and checked for completeness. Complete patient summary sheets that include the following: active and past problem list, allergies, active and past medications, significant family history, social history, preventive medical services including pap smears, mammograms, diabetes and cholesterol screening; and previous surgeries and hospitalizations. Compliance with the mentioned parameters will be measured with the current system then again in 6 months post implementation. And again every 6 months to compare treads of compliance with quality measures. Any issues or problems in populating the required fields will be brought up and resolved with one-one meetings between the QA personnel and the medical provider. Quality of medical care is of prime importance to all CHC staff and is part of the culture where best clinical practices are encouraged. The EHR system will help us achieve uniformity in these practice methods. We are challenged to insure that the level of quality of care will improve with the implementation of an EHR for the CHC system of clinics.

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6 Final project Wrap-up 6.1 Master Procurement plan

Situation Community Health Connections will deploy the OpenVista systems for its network of three ambulatory care centers and a mobile medical unit. In support of this EHR implementation various hardware, software and resources will be identified and requested by the various project teams. Goals Timely procurement and delivery of the items is essential to follow the project implementation schedule. A goal is to ensure excellence in procured items while minimizing expenditures. Tradeoffs or substitutes of equipment may occur, but the expected benefits of the project cannot be sacrificed, such as: 1) patient quality, 2) responsiveness to patient needs, 3) improvement of staff efficiency and 4) system/hardware reliability. Process The strategic procurement process will include the following: 1. Procurement data is established by initially gathering a key understanding of: 1) the needs of the staff, 2) the defined process for the EHR implementation, 3) the potential suppliers and 4) the budget for investment. 2. Stakeholders and staff team members are interviewed to compile a list of mus t/want items. 3. Specifications and requirements for the major hardware and software are prepared. 4. Potential suppliers are identified whom may satisfy the requirements. Contact/communication and investigation begins if a relationship is not already established. 5. An RFQ will be used to obtain official documentation on the major hardware and the procurement/customization of OpenVista EHR RFPs will be reviewed by the implementation team representatives, financial group and the legal department for content and completeness. 6. Two to three vendors will be identified for the less costly or "off the shelf" HW, SW and resources requested. Corresponding staff representatives will evaluate options by considering such items as technology, quality, delivery, cost and ve ndor financials.

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7. Vendors will be selected based on the staff evaluation/scorecards. Contracts will be written with delivery and confidentiality agreement included. 8. Vendor will be contacted weekly for status update and to discuss any issues hindering the project and any potential areas where quality, delivery and cost may be negatively impacted. 9. In the instance where Meaningful Use items are purchased with the grant money, those purchase orders will capture the appropriate accounts to track those expenses. Assumptions 13. The included list of actual procurement items are based on input from the hardware and software teams (see appendix). Any deviations will be reviewed by the implementation team.

6.2

Financial Analysis

Community Health Connections has been given a grant of $1.6M to implement an EHR system. Our organization has chosen Medsphere's OpenVista open source application to ultimately improve patient care. The reality is that the implementation will require a significant investment in infrastructure, including hardware, software and personnel resources to ensure that we achieve our goal. The following financial analysis is based on the benefits of implementing the EHR solution and incremental costs incurred. Challenges: As with all financial analysis, the results are only as good as the assumptions. They have been gathered from the workflow, software, hardware teams and leveraged from existing resources on this topic. Ensuring we qualify for the Meaningful Use incentives will be a significant endeavor in itself, along with adoption of the application. Without qualification of the criteria, our financial position is weakened. We anticipate productivity will be lost for about 7 months, during the training months and initial rollout, ranging from 10-25% loss in efficiency. We project hardware costs to be approximately $330K and software costs to be $73K during the first year. Over the course of 6 years, we anticipate software costs to be around $444K largely driven by the cache licensing and assistance. Staffing costs will be approximately $4M over the same period. Incremental expenses will include temporary (abstractors, software contractor, hardware contractors, training specialists, backfilled medical staff during training) permanent (Meaningful Use Specialist, process analyst, 2 software DBAs, providers to meet increasing demand) headcount and overtime costs during training.

Benefits:

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The largest income stream will come from the Meaningful Use payments from Medicaid reimbursements ($28-103K/mo.) and significant savings will come from labor efficiencies ($18+K/mo.) , and reduction in transcription costs. Savings will also be incurred in a number of areas ranging from reduced materials fees, reduced storage space to maintain files, elimination of manual processes. We anticipate increased number of patient visits as a result of labor efficiencies from system implementation ($38K/mo.) as well as improved patient service, quality of care and reputation stimulating demand for our services, starting in year 3.

Results: Using variable rates for the Net Present Value analysis: 8%, 10%, 12%, 14%, 16%, assuming we receive 100% of the maximum Meaningful Use payments, we calculate the NPV to be $8.9M, $7.8M, $6.9M, $6.1M and $5.4M respectively. Our Internal Rate of Return is 5.8%. Sensitivity analysis based on receiving 40-100% of Meaningful Use payments indicates that the project is still yields a considerable benefit even if CHC is unable to qualify for full incentive reimbursements. Breakeven occurs in month 21.

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Please see appendix for further details to the financial analysis, including assumptions.

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Appendices

Post Appointment Order Form

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Diabetic Flow Sheet

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Well Woman Visit Encounter Form

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Procurement Plan Items

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Financial Analysis Final Assumptions

Who

Savings Keri & Carmen V.

What

>30% of a patients are Medicaid patients. Go-No Go in October 2010. See savings kick in Mar 2011 and MU payments in May 2011. 39 Eligible Providers (16 MDs and 23 RNPs). FQHC clinics do not qualif y, staff "deemed" federal employees for the purposes of medical malpractice and thereby become immune from law suit. Assumed exis ting storage off -site then storage reduction of 500 ft after 2 years, another 500 ft after 4th year Start to see increase in number of patients due to successful implementation of EHR, 5% growth rate after first year Flowchart savings: 20% before EHR, 0% afterwards, paper costs Pre-EHR for 100% of the visits, physicians fill out a Superbill. Post-EMR, there w ill be no Superbills generated by hand (but 5% patients request) For each new patient, 95% of H&P are transcribed and involves 1/4 hr transcription time at $20/hr For existing patients, 5% transcription usage, 1/4 hr at $20/hr Misc. admin. paper and faxes = 250 * $0.05 per day Misc. mailings per day = 30 @ $0.44 postage, with 8% postal increase annually We have Mirth installed (as our existing systems are already talking to each other via the engine) and our only cost would be associated w ith adding necessary interfaces (doing the analysis and configuration work) and we are not expecting any additional license fees. 2 FTE Technologists needed, 1 FTE contractor Total patient visits per year between all clinics is 145,770, and 12,147 patients per month total, 21.5 clinic days/month, approx. 560 patients total per day, and central clinic sees twic e as many patients as East and West, so therefore: New patients per day = 195 (5 new pt / provider / day. Today's downward turniing economy and the public losing their employer sponsered health plan, more and more people are accessing community clinic for their care, 16 MDs+23 RNPS). Increase in patient load over time due to increase in patient satisfaction (per A. Guiterrez); assumed 5% yearly 10-15% loss in productiv ity for first several months (use 6 months) - actually used 20% productiv ity loss in Oct, 15% in Nov, 15% in Dec, 25% in Jan-Feb, 15% in March, 10% in April If a patient has not been to the clinic in three years, it is permissible to treat that person as a new patient via electronic entry, no data migration Since the assumption is that the PMS is already in place, there are no savings gain from encounter charge and payment postings; they were alr eady automated Medsphere does not provide the .com version for clinics (per Warren); therefore, we are going w ith open source and using internal sources to implement and build adapters Financial Analysis Info\Staff numbers.pdf Meaningful Use Specialist: 1 FTE, $50,000 salary + overhead 2 FTE for DBAs, 1 temporary DBA Pay increase rate 3% first year, 5% next tw o years, 7% ongoing years Training specialists - 2 FTE for 5 days No incremental resources needed for patient registry and payment posting, post-EMR implementation 1 FTE for EMR process analysis For data migration, abstractor at each clinic location with extra at central (4 FTE times 2 years, then 1 FTE times 1 year) Backfill MDs, RNPs and nurses (Superusers) while they are being trained.

Keri Sheldon Keri Keri Keri/Regina Regina/Elizabeth Keri/Luis Keri Keri

Software:

David David

Operations

Jean & Team Luis Keri Book/Keri Sheldon/Tom Elizabeth/Keri/Regina

Project Staffing

David, Keri Sarah Carmen V./Keri David M. Keri Carmen M. Regina Jean & Team Sheldon Jean/Carmen/Keri

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Meaningful Use Tables

Table 1 Meaningful Use EHR Incenti ves

Maximum Incentive Payment Amount for Medicaid Professionals

Cap on Net Average Allowable Costs, per the HITECH Act $25,000 in Year 1 for most professionals $10,000 in Years 2-6 for most professionals $16,667 in Year 1 for pediatricians with a minimum 20% patient volume, but less than 30% patient volume, Medicaid patients $6,667 in Years 2-6 for most professionals pediatricians with a minimum 20% patient volume, but less than 30% patient volume, Medicaid patients

Table 2 Meaningful Use EHR Incenti ves

85% Allowed for Eligible Professionals $21,250 8,500 14,167

Maximum Cumulative Incentive Over 6Year Period

63,750

5,667

42,500

Payment Scenarios for Medicaid EPs Who Begin Adoption in the First Year

Calendar Year 2011 $21,250 8,500 8,500 8,500 8,500 8,500 Medicaid EPs who Begin Adoption in: 2012 $21,250 8,500 8,500 8,500 8,500 8,500 $21,250 8,500 8,500 8,500 8,500 8,500 $21,250 8,500 8,500 8,500 8,500 8,500 $21,250 8,500 8,500 8,500 8,500 8,500 $21,250 8,500 8,500 8,500 8,500 2013 2014 2015 2016

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

2021 8,500 Total 63,750 63,750 63,750 63,750 63,750 63,750 * Medicaid EPs are limited to 85% of $65K, $25K, and $10K on net allowable costs.

Sources for Table 1 and 2: Federal Register / Vo l. 75, No. 8 / Wednesday, January 13, 2010 / Proposed Rules

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TABLE 3: Stage 1 Objectives, Features that make up certified EHR System, Meaningful Use Measures.

Meaningful Use Stage 1 Objectives Use Computer Provider Order Entry (CPOE) Corre sponding EHR Software Features Enable a user to electronically record, store, retrieve, and manage, at a minimum, the following order types: Medications; Laboratory; Radiology/imaging; Provider referrals; Blood bank; Physical therapy; Occupational therapy; Respirat ory therapy; Rehabilitation therapy; Dialysis; Provi der consults; and Discharge and transfer. (1) Real-time, alerts at the point of care for drug-drug and drug-allergy contraindications; (2) Electronic ally check if drugs are in a formulary or preferred drug list; (3) Provide certain users rights to deactivate, modify, and add rules for drug drug and drug-allergy checking; (4) Track number of alerts users respond to Electronically record, modify, and retrieve a patient's problem list over multiple visits Meaningful Use Measure s CPOE is used for at least 80% of all orders; 10% for hospitals

Implement drug/allergy checks

Function is enabled

Maintain an up-to-date problem list of current and active diagnose s based on ICD-9-CM or SNOMED CT® E-pre scribing

At least 80% of all unique patients have at least one entry or an indication of none recorded. At least 75% of all permissible prescriptions written by the EP are transmitted electronically At least 80% of all unique patients have at least one entry or an indication of "none" At least 80% of all unique patients have demographics recorded For at least 80 percent of all unique patients age 2 and over seen by the EP or admitted to the eligible hospital, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20 At least 80% of all unique patients 13 years old or older have "smoking status" recorded At least 50% of all clinical lab tests results are incorporated as structured data

Electronically transmit prescriptions

Maintain active medication/allergy list

Electronically record, modify, and retrieve a patient's active medication/ allergy list

Record demographics

Electronically record, modify, and retrieve patient demographic dat a (1) Enable a user to electronically record, modify, and retrieve a patient's vital signs; (2) Automatically calculate and display body mass index (BMI); (3) Plot and electronically display, upon request, growth charts for patients 2-20 years old.

Record and chart changes in vital signs

Record smoking status for patients 13 years old or older Incorporate clinical labtest results into EHR a s structured data

Electronically record, modify, and retrieve the smoking status of patient

(1) Electronically receive clinical laboratory test results and display such results in human readable format; (2) Electronically display in human readable format any clinical laboratory tests that have been received with LOINC® codes; (3) Electronically display all the information for a test report; (4) Electronically updat e a patient 's record based upon received

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Meaningful Use Objectives Generate lists of patients by specific conditions Report ambulatory quality measure s to CMS or the States Send reminders to patients for preventive/follow-up care Implement five clinical decision support rules relevant to specialty or high clinical priority

laboratory test results Corre sponding EHR Software Features Electronically select, sort, retrieve, and output a list of patients and patients' clinical information (1) Calculat e and electronically display quality measure results as specified by CMS or states; (2) Electronically submit calculated quality measures Electronically generate a patient reminder list for preventive or follow-up care (1) Implement automat ed, electronic clinical decision support rules according to specialty or clinical priorities; (2) Aut omatically and electronic ally generate real-time alerts and care suggestions based upon clinical decision support rules and evidence grade; (3) Automatically and electronic ally track, record, and generate reports on the number of alerts responded to by a user Electronically record and display patients' insurance eligibility, and submit insurance eligibility queries Electronically submit claims

Meaningful Use Measure s Generat e at least one report listing patients with a specific condition For 2011, an EP/hospital would attest this has been done Reminders sent to at least 50% of all unique patients that are 50 and over Implement five clinical decision support rules relevant to the clinical quality metrics the EP/Eligible Hospital is responsible for

Check insurance eligibility electronically

Submit claims electronically to public and private payers. Provide patients with an electronic copy of their health information upon request Provide patients with electronic access to their health information within 96 hours of the information being available Provide clinical summaries to patients for each office visit.

Insuranc e eligibility checked electronically for at least 80% of all unique patients At least 80 % of all claims filed electronically At least 80% of all patients who request an electronic copy of their health information are provided it within 48 hours At least 10% of all unique patients are provided timely electronic access to their health information

Enable a user to create an electronic copy of a patient's clinical information and provide to a patient on electronic media, or through some other electronic means Enable a user to provide patients with online access to their clinical information

(1) Enable a user to provide clinical summaries to patients (in paper or electronic form) for each office visit; (2) If the clinical summary is provided electronically (i.e., not printed), it must be provided in: 1) human readable format; and 2) and on electronic media, or through some other electronic means.

Clinical summaries provided to patients for at least 80% of all office visits

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Meaningful Use Objective s

Corre sponding EHR Software Meaningful Use Measure s Features Exchange key clinical (1) Electronically receive a Provide summary of care record information among providers patient summary record, from for at least 80 % of transitions of of care and patient authorized other providers and care and referrals; Perform at entities electronically and organizations; (2) Electronically least one test of certified EHR provide summary care record transmit a patient summary technology's capacity to record, to other providers and electronic ally exchange key organizations clinical information Perform medication Electronically complete Perform medication reconciliation reconciliation at relevant medication reconciliation of two for at least 80 % of relevant encounters and each transition or more medication lists into a encounters and transitions of of care and referral single medication list that can be care electronic ally displayed in real time Submit electronic data to Electronically record, ret rieve, Performed at least one test immunization registrie s and and transmit immunization submission to immunization actual submi ssion where information to immunization registries and public health required and accepted registries agencies Provide electronic syndromic Electronically record, ret rieve, Performed at least one test of surveillance data to public and transmit syndrome-based certified EHR technology's health agencies and actual (e.g., influenz a like illness) public capacity to provide electronic transmi ssion according to health surveillance information to syndromic surveillance dat a to applicable law and practice public health agencies public health agencies Protect electronic health (1) Assign unique user names; Conduct or review a security risk information through the (2) Permit certain us ers to analysis and implement security implementation of appropriate access health information in an updates as necessary technical capabilities emergency; (3) Terminate an electronic session after a predetermined time of inactivity; (4) Encry pt and decrypt electronic health information that is stored and exchanged; (5) Record actions (e.g., deletion) related to electronic health information; (6) Track alterations of electronic health information; (7) Set up user verification measures; (8) Record disclosures made for treatment, payment, and health care operations NOTE: This table outlines what Stage 1 Objectives define meaningful use; what software features are necessary to accomplish these objectives; and what criteria the government will use to measure meaningful use. EP = Eligible Providers/Professionals Source: http://www.soft wareadvice.com/articles/medical/the -stimulus-bill-and-meaningful-use-of-qualifiedemrs-1031209/

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Table 4: Meaningful Use Required Numerators, Denominators and Meaningful Use Objective s Corre sponding Numerator and Denominator (if applicable) Use Comput er Provider Order Numerator = number of orders Entry (CPOE ) issued by EP entered using the CPOE functionality of "certified EHR technology" during the EHR reporting period. Denominator= all orders issued by the EP during the EHR reporting period Implement drug/allergy checks Not Applicable Maintain an up-to-date problem Numerator= number of unique list of current and active patients seen by the EP during diagnoses based on ICD-9-CM the EHR reporting period that or SNOMED CT® have at least one ICD-9- CM or SNOME D CT-c oded ent ry or an indication of "none" in the problem list. Denominator= number of unique patients seen by the EP during the EHR reporting period. E-prescribing (eRx): Generate and transmit permissible prescriptions electronically. Numerator= number of prescriptions generated and transmitted electronically during the EHR reporting period, excluding controlled substances. Denominator= number of prescriptions written for during the EHR reporting period, excluding controlled substances. Acti ve medication List: Numerator= number of unique patients seen by the EP during the EHR reporting period who have at least one entry (or an indication of "none" if the patient is not currently prescribed any medication) recorded as structured data in their medication list. Denominator= number of unique patients seen by the EP during the EHR reporting period. Acti ve Allergy List: Numerator=number of unique patients seen by the EP during the EHR reporting period who have at least one entry (or an indication of "none" ) recorded as structured data in their allergy list. Denominator= number of unique patients seen by the EP during the EHR reporting period.

Implementation Plan

Percentages Meaningful Use Measure s CPOE is used for at least 80% of all orders

Function is enabled At least 80% of all unique patients have at least one entry or an indication of none recorded. Note: "Unique patient" means that even if a patient is seen multiple times during the EHR reporting period they are only counted once. At least 75% of all permissible prescriptions written by the EP are transmitted electronically

Maintain active medication/allergy list

At least 80% of all unique patients have at least one entry or an indication of "none"

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Meaningful Use Objective s Record demographics

Record and chart changes in vital signs

Record smoking status for patients 13 years old or older

Corre sponding Numerator and Denominator (if applicable) Numerator=number of unique patients seen by the EP during the EHR reporting period who have all required demographic elements (preferred language, insurance type, gender, race, and et hnicity, date of birth) recorded as structured data in their electronic record. Denominator= number of unique patients seen by the EP during the EHR reporting period. Numerator= number of unique patients age 2 and over seen by the EP during the EHR reporting period who have a record of their blood pressure, and BMI (growt h charts for patients 2-20 years old) in their record. Denominator= number of unique patients age 2 or over seen by the EP during the EHR reporting period. Numerator= number of unique patients age 13 or older seen by the EP during the HE R reporting period who have a record of their smoking status. Denominator= number of unique patients age 13 or older seen by the EP during the EHR reporting period. Numerator= number of lab tests ordered during the EHR reporting period by the EP whose res ults are expressed in a positive or negative affirmation or as a number and are incorporat ed as structured data into certified EHR technology. Denominator= number of lab tests ordered during the EHR reporting period by the EP whose results are expressed in a positive or negative affirmation or as a number. Not Applicable

Meaningful Use Measure s At least 80% of all unique patients have demographics recorded

For at least 80 percent of all unique patients age 2 and over seen by the EP or admitted to the eligible hospital, rec ord blood pressure and BMI; additionally, plot growth chart for children age 2 to 20

At least 80% of all unique patients 13 years old or older have "smoking status" recorded

Incorporate clinical lab-test results into EHR as structured data

At least 50% of all clinical lab tests results are incorporat ed as structured data

Generat e lists of patients by specific conditions

Generat e at least one report listing patients with a specific condition

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Meaningful Use Objective s Report ambulat ory quality measures to CMS or the States (EP only)

Corre sponding Numerator and Denominator (if applicable) Not Applicable

Meaningful Use Measure s For 2011, an EP would attest this has been done. For 2012, measures must be electronically submitted bot h as per Federal Register II (A) (3). Reminders sent to at least 50% of all unique patients that are 50 and over

Send reminders to patients for preventive/follow-up care

Numerator= number or unique patients age 50 or over seen by the EP during the EHR reporting period who are provided reminders. Denominator= number of unique patients age 50 or older seen by the EP during the EHR reporting period. Not Applicable

Implement five clinical decision support rules relevant to specialty or high clinical priority Check insurance eligibility electronic ally

Implement five clinical decision support rules relevant to the clinical quality metrics the Insuranc e eligibility checked electronic ally for at least 80% of all unique patients

Numerator= number of unique patients seen by the EP during the EHR reporting period whose insurance eligibility is checked electronic ally. Denominator= number of unique patients seen by the EP during the EHR reporting period whose insurer allows for the electronic verification of eligibility.

Submit claims electronically to public and privat e payers.

Numerator= number of claims submitted electronically using the certified EHR technology for patients seen by the EP during the EHR reporting period. Denominator= number of claims filed by the EP during the EHR reporting period. Numerator= number of patients seen by the EP during the HER reporting period that request an electronic copy of their healt h information and receive it within 48 hours. Denominator= number of patients seen by the EP who request an electronic copy of their health information during the EHR reporting period.

At least 80 % of all claims filed electronic ally

Provide patients with an electronic copy of their healt h information upon request (including diagnostic test results, problem list, medication lists, and allergies)

At least 80% of all patients who request an electronic copy of their health information are provided it within 48 hours

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Meaningful Use Objective s Provide patients with electronic access to their health information within 96 hours of the information being available to the EP (including lab results, medication lists, allergies ) Note: Electronic access may be provided by a number of secure electronic methods (e.g. PHR, patient portal, CD, USB drive). Provide clinical summaries to patients for each office visit. Note: After-visit clinical summary contains an updated medication list, laboratory and other diagnostic te st orders, procedure s and other instructions ba sed on clinical discussi ons that took place during the office vi sit.

Corre sponding Numerator and Denominator (if applicable) Numerator= number of unique patients seen during the E HR reporting period who have timely, electronic access to their health information (for example, have established a user account and password on a patient portal). Denominator= number of unique patients seen during the E HR reporting period.

Meaningful Use Measure s At least 10% of all unique patients are provided timely electronic access to their health information Note: Timely is defined as within 96 hours of information being available to the EP either through the receipt of final lab results or a patient interaction that updates the EP's knowledge of the patients' health. Clinical summaries provided to patients for at least 80% of all office visits Provide summary of care record for at least 80 % of transitions of care and referrals;

Numerator= number of unique patients seen during the E HR reporting period who are provided a clinical summary of their visit. Denominator= number of unique patients seen in the office during the EHR reporting period

Provide Summary of Care record for each transition of care and referral.

Exchange key clinical information among providers of care and patient authorized entities electronic ally and Perform medication reconciliation at relevant encounters and each transition of care and referral Note: "Transition of care" i s the transfer of a patient from one clinical setting (inpatient, outpatient, physician office, home health, rehab, long-term care facility, etc.) to another or from one EP to another.

Implementation Plan

Numerator= number of transitions of care and referrals for which the EP was the transferring or referring provider during the E HR reporting period where a summary of care record was provided. Denominator= number of transitions of care for which the EP was the trans ferring or referring provider during the EHR reporting period. Not Applicable

Note: Clinic al summary can be provided through a PHR, patient portal, secure mail, electronic media such as CD or USB fob, or printed copy. Provide summary of care record for at least 80% of transitions of care and referrals. Note: Summary of care record can be provided through an electronic exchange, accessed through a secure portal, secure email, electronic media such as CD or USB fob, or print ed copy.

Numerator= number of relevant encounters and transitions of care for which the EP was a participant during the EHR reporting period where medication reconciliation was performed. Denominator= number of relevant encounters and transitions of care for which the EP was a participant during the EHR reporting period.

Perform at least one test of certified EHR technology's capacity to electronically exchange key clinical information Perform medication reconciliation for at least 80 % of relevant encounters and transitions of care Note: "Relevant encounter" is any encounter that the EP judges a medication reconciliation is due to new medication or long gaps in time between patient encounters or other reasons determined by the EP.

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Meaningful Use Objective s Submit electronic data to immunization registries and actual submission where required and accepted Provide electronic syndromic surveillance data to public healt h agencies and actual transmission according to applicable law and practice Protect electronic health information through the implementation of appropriate technical capabilities Submit electronic data to immunization registries and actual submission where required and accepted Provide electronic submission of reportable lab results to public health agencies and actual submission where it can be received (Hospital only) Provide electronic syndromic surveillance data to public healt h agencies and actual transmission according to applicable law and practice Protect electronic health information through the implementation of appropriate technical capabilities

Corre sponding Numerator and Denominators (if applicable) Not Applicable

Meaningful Use Measure s Performed at least one test submission to immunization registries and public health agencies Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance dat a to public health agencies Conduct or review a security risk analysis and implement security updates as necessary Performed at least one test submission to immunization registries and public health agencies Performed at least one test of certified EHR technology capacity to provide electronic submission of report able lab results to public health agencies Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance dat a to public health agencies Conduct or review a security risk analysis and implement security updates as necessary

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Not Applicable

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TABLE 5: MEANINGFUL USE BY CATEGORY WITH ASSOCIAT ED MET RICS AND WHO WILL BE RESPONSIBLE PART IES DURING AND POST IMPLEMENT ATION. Health Outcomes Policy Priority Metrics Im plementation PostIm plementation

Im prove quality, safety efficiency and reduce health disparities (Objectives 1-16)

CPOE; Drug-drug interaction; Activ e problem list; e-Rx; Active medication/allergy list; Demographics; Vital signs and smoking status, incorporate lab test results into EHR, Generate lists of patients by specif ic conditions, Report ambulatory quality measures; Patient Reminders; 5 clinical decision support rules; Check insurance eligibility and submit claims electronically Provide patient w ith copy of electronic health information and clinical summaries w ithin federally mandated time limit

Physicians, Nursing Staff, Software Analyst, Application Support Analyst, Medical Records staff, MU Specialist

Physician and Nursing Staff, Medical Records Staff, Application Support Analyst, QA/MU Specialist

Engage Patients and fam ilies (Objectives 17-19) Im prove care coordination (Objectives 20-22)

Physicians and Nursing staff, Medical Records staff, Application Support Analyst, MU Specialist Physicians, Nursing Staff, Software Analyst, Application Support Analyst, Medical Records staff, MU Specialist Physicians, Nursing Staff, Software Analyst, Application Support Analyst, Medical Records staff, MU Specialist IT hardware/software Support, MU Specialist

Physician and Nursing Staff, Medical Records Staff,

Electronically exchange key clinical information among providers of care and patient authorized entities; Medication reconciliation

Physician and Nursing Staff, Medical Records Staff

Im prove population and public health (Objectives 23-24)

Submit electronic data to immunization registries; Provide & transmit electronic surveillance data to public health agencies

Physician and Nursing Staff, Medical Records Staff, QA/MU specialist

Ensure adequate privacy and security protection for personal health information (Objective 25)

Conduct & Review security risk analysis; Implement security updates as necessary; Ensure full compliance with HIPAA Privacy and Security Rules

IT Support/Security Officer

Implementation Plan

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Table 6: COMMUNITY HEALTH CENTER'S PROGRESS TO MEETING STAGE 1 MEANINGFUL USE CRIT ERIA Health Outcomes Policy Priority Objectives Metrics Collaborative Teams Throughout Meaningful Use Stages

Im prove quality, safety efficiency and reduce health disparities (Objectives 1-16)

CPOE; Drug-drug interaction; Active problem list; e-Rx; Active medication/allergy list; Demographics; Vital signs and smoking status, incorporate lab test results into EHR, Generate lists of patients by specif ic conditions, Report ambulatory quality measures; Patient Reminders; 5 clinical decis ion support rules; Check insurance eligibility and submit claims electronically Provide patient w ith copy of electronic health information and clinical summaries w ithin federally mandated time limit

Recording of structured data, Physician and Nursing Staff, Medical Attestation, Generation of Reports, Records Staff, Application Support electronic submission/transmittal, Analyst, QA/MU Specialist patient reminders Required percentage measures: 50%, 75%, 80%

Engage Patients and fam ilies (Objectives 17-19)

Access provided via patient portal or Physician and Nursing Staff, Medical printed copy. Perform test of Records Staff, systems capability. Required percentage measures: 10% and 80% Mandated Timeframes: 48 hours, 96 hours

Im prove care coordination (Objectives 20-22) Im prove population and public health (Objectives 23-24)

Electronically exchange key clinical information among providers of care and patient authorized entities; Medication reconciliation Submit electronic data to immunization registries; Provide & transmit electronic surveillance data to public health agencies

Medication reconciliation, clinical Physician and Nursing Staff, Medical information exchange are performed Records Staff Perform test of systems capability Required percentage measure 80% Submit and transmit electronically to Physician and Nursing Staff, Medical registries Records Staff, QA/MU specialist Perform test of systems capability

Ensure adequate privacy and security protection for personal health inform ation (Objective 25)

Conduct & Review security risk analysis; Implement security updates as necessary; Ensure full compliance w ith HIPAA Privacy and Security Rules

Conduct or review security risk analysis and implement security updates as necessary Perform test of systems capabilities

IT Support/Security Offic er

Table groups Stage 1 25 Meaningful Use Objectives into 5 main categories. Table shows how we are progressing via color scheme. Color scale: Green = On track ; Yellow= some concerns, some issues in category that are beyond our control. Currently CHC has met all 25 Stage 1 Criteria. Therefore, all categories should be green but the reality is that they are not. The reason is to show that inform ation exchange still poses some challenges and not all agencies and providers that CHC interacts w ith are presently NHIN com pliant.

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Financial Analysis Calculation Details

Refer to CHC Financial Analysis Appendix.pdf

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