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Integrated EHR Systems for Multi-Agency Consortiums

Representative: Ben Bredesen Vice-President, Marketing Qualifacts Systems, Inc. nd 200 2 Avenue South Nashville, TN 37201 Office: 615-493-5206 [email protected] Editor: Shannon T. Harvey, LCSW Project Manager, Peachstate Information Network August 2007 to present Chief Executive Officer, River Edge Behavioral Health Center February 2009 ­ 175 Emery Highway Macon, Georgia 31217 Office: 478-751-4515 [email protected]

QUALIFACTS SYSTEMS, INC.

Integrated EHR Systems for

Multi-Agency Consortiums

Information in this document, including URL and other Internet Web site references, is subject to change without notice. Unless otherwise noted, the example companies, organizations, products, domain names, e-mail addresses, logos, people, places and events depicted herein are fictitious, and no association with any real company, organization, product, domain name, e-mail address, logo, person, place or event is intended or should be inferred. Complying with all applicable copyright laws is the responsibility of the user. Without limiting the rights under copyright, no part of this document may be reproduced, stored in or introduced into a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise), or for any purpose, without the express written permission of Qualifacts Systems, Inc. The names of actual companies and products mentioned herein may be the trademarks of their respective owners. ©2009. Qualifacts Systems, Inc. All rights reserved. 200 2nd Avenue South Nashville, TN 37201 Phone 615.386.6755 · Fax 615.386.1225

Economy Accelerates the Demand for Enterprise Systems - 2

Economy Accelerates the Demand for Enterprise Systems

Today's difficult economic environment has Behavioral Health and Human Service providers struggling to balance budgets that were already severely constrained. Additional pressure from payers and regulatory authorities to secure prior authorizations and deliver outcomes measurements has added to agencies' administrative burdens. Electronic Health Record (EHR) systems have long been touted as an efficient tool to help agencies deal with these challenges and yet fewer than 20% of the Behavioral Health providers in the U.S. have successfully implemented EHR systems. According to Scott Lloyd, Vice-President, MTM Services, "The reality for a lot of providers in all funding environments (e.g. fee-for-service, grant funded, per member per month, per diem) is that they are not able to accurately show what services they have delivered in exchange for the funding they have received due to a lack of electronic systems that quickly quantify the organization's direct service delivery efforts". Mr. Lloyd continues, "In the absence of accurate reporting from their providers, multiple states have resorted to calculating and utilizing estimated rates per hour, per day, or per event to make key funding decisions. While providers question the accuracy of these estimated hourly costs they are challenged to produce the data to support their case and despite the overwhelming need for systems that would provide quick answers to these basic questions adoption of integrated EHRs remains very low". Why? There are three primary reasons. Software vendors have failed to deliver on their promises. Some providers have decided to develop `home-grown' or custom systems without the expertise to do so. Providers have often underestimated the financial and manpower requirements to successfully implement. As a result, software projects have run over budget and behind schedule, functionality has not met business needs, and available functionality has been inadequately utilized. It is not surprising that an estimated 70% of the agencies that made the commitment to move to enterprise EHR and billing systems (both commercial and `home-grown') over the last 20 years have failed to fully operationalize their chosen system. But all that is changing.

Agencies are Forming Consortiums To Meet the Challenge

Over the past few years, there has been a significant increase in the number of provider organizations forming multi-agency consortiums to jointly select, contract for, implement and operationalize an enterprisewide electronic health record and billing system. Most providers believe that the move from a paper or dated electronic systems to a modern system will result in significant benefits to their organizations, including: More efficient service delivery, improved response to managed care demands, cleaner audits, greater access to information and improved client care. While many providers can articulate these benefits, most are facing budgetary and staffing constraints that prevent them from either considering or making this change successfully. Even individual agencies that have resources to pursue this path still face the obstacle of achieving an on-time and on-budget implementation. Agencies commonly form partnerships to: Leverage vendor negotiations, reduce implementation costs, and harness the power of collaboration on best practices in workflow and back office operations. Consortium members contend their combined efforts help guarantee successful implementations and more effective use of an enterprise software system.

Integrated EHR Systems for

Multi-Agency Consortiums © 2009 Qualifacts Systems, Inc. All rights reserved

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The Benefits of Consortium Membership

Consortium members report a variety of benefits when multiple agencies work together to implement EHR and billing systems. Two, Three or Four Heads Are Better Than One. Across the country, providers that implemented first generation enterprise software systems most typically automated existing processes and workflow. In many cases, the providers subsequently realized that while they had made existing processes faster these processes were still inadequate and unreliable. At the heart of any multi-agency consortium is collaboration among the members. Working together especially when led by an experienced IT consultant and facilitator with deep knowledge of state-specific requirements - members establish common, best practice workflow and documentation to build a system that is both effective and dependable. Setting and Maintaining the Strategic Direction

Consortiums that have implemented software successfully have done four critically important things related to strategic direction: (1) Clarify the strategic goals of the initiative at the outset and measure all activities and decisions against these goals. (2) Select a trustworthy, third-party IT consultant with knowledge of the healthcare industry and directive facilitation skills. (3) Select a project manager with knowledge of the industry and those same directive facilitation skills. (4) Executives remain engaged throughout the process, supporting the project manager to deliver the project on time and on budget with full utilization of truly relevant functionality to support business and clinical needs. Types of Consortiums Being Formed The three types of consortiums most often developed by member agencies are: Loosely Affiliated Buying Groups The first type of consortium is a loose affiliation membership. Individual agencies recognize that the RFP process for stand-alone agencies is a lengthy, often prohibitively expensive and time consuming proposition for staff who may only have limited IT knowledge. This type of consortium typically engages a consultant to help manage the initial search process and develop a scoring mechanism by which vendors are evaluated. The advantage of this approach is that a consultant who is experienced in the selection of EHR systems can help consortium members quickly and objectively narrow the field of potential vendors. Additionally, multiple parties can share the cost of the IT consulting group, where this expertise might have been beyond the reach of a single agency.

Tightly Affiliated Groups

In the second type of consortium agency members are much more integrated. The consortium forms a legal partnership structure and agrees to establish common business processes, workflow, naming conventions, clinical documentation and even billing conventions. The tightly integrated model will generally rely on a single consultant to manage the decision process for the group.

Integrated EHR Systems for

Multi-Agency Consortiums © 2009 Qualifacts Systems, Inc. All rights reserved

Consortium Case Study: Peachstate Information Network - 4

While this model has the same advantages in software selection and cost reduction as the loosely affiliated model, it has the added benefit of assisting member organizations to critically evaluate their business processes and documentation against best practices. Tightly affiliated groups use the implementation of an EHR system as a catalyst to critically evaluate and adjust the effectiveness and efficiency of each clinical and business process. It is common that each agency in the partnership has different strengths and working together disseminates the strengths and results in sharing of best practices, reducing inefficiencies, improving clinical and billing effectiveness, and higher rates of user adoption. Shared Administrative Functionality The third consortium type is one in which the members share administrative responsibility. In this model, the agency with the strongest skill set in a particular area performs a function for all members. Functions that are typically centralized include; system administration, training and billing. The shared administrative model offers the greatest potential benefits to member agencies. This pooling of resources reduces the redundant administrative burden for each agency, freeing energy for mission focus. Just as importantly, smaller agencies can access an EHR system that they would be unable to afford as a sole purchaser.

Consortium Case Study: Peachstate Information Network

The Peachstate Information Network (PIN) is a Georgia-based 501(c)3 comprised of four Community Service Boards (CSBs). CSBs are public corporations and instrumentalities of the state providing Georgia's most comprehensive set of mental health, addictive disease and mental retardation services for children, adolescents and adults. As a result, CSBs work with similar - though very complicated - managed care companies and payers. The CSB members of PIN are: Cobb-Douglas CSB (CEO Tod Citron, LCSW, MPA, who is also the Chairman of the Board of PIN). River Edge Behavioral Health Center (CEO Shannon Harvey, LCSW), Avita Community Partners (CEO Carol Perkins, M. Ed.), and Advantage Behavioral Health (CEO Cindy Darden, Ph.D.). Together, the PIN member agencies annually serve 30,000 Georgians in 30 counties in the state's mountainous northeast, metro Atlanta, and rural/suburban central regions. (Their service areas are not contiguous.) "PIN was born out of previous positive collaborative experience among the partners," explains PIN Project Manager and River Edge CEO Shannon Harvey. "In the past, we had come together around managed care contract language negotiations and secured bigger wins with a larger footprint." From that success, PIN's inaugural members (Avita, Cobb/Douglas and River Edge) conceptualized the formation of an IT solution purchase/implementation consortium in 2005. At that time, Cobb/Douglas was seeking to move from their homegrown system as they were experiencing irresolvable billing issues and enormous resource bleeds due to system support needs. Avita was seeking to leave an unresponsive vendor, and River Edge was seeking its first EHR purchase. The agencies' leaders believed they would gain cost-savings and efficiencies by jointly selecting an EHR product. Over time, PIN members further recognized the value that a tight affiliation would bring in contracting, implementation and ongoing system administration for the eventual system serving more than 1,000 users. The PIN model is most closely represented by the "Tightly Affiliated Model" described above. The PIN leaders recognized the difficulty in selecting an enterprise software system for one agency and knew that there would be significantly more work to coordinate the requirements of three agencies. As a result, PIN selected IBM Healthlink for consulting services to work alongside a trusted internal facilitator who had deep knowledge of CSB service offerings, authorization and payor needs.

Integrated EHR Systems for

Multi-Agency Consortiums © 2009 Qualifacts Systems, Inc. All rights reserved

Consortium Case Study: Peachstate Information Network - 5

Strategic Direction: In Practice At the outset, PIN members recognized the need to jointly identify their common strategic goals against which all activities and decisions would be measured.

Directives of the PIN member agencies' CEOs

1. Everyone will use electronic scheduling. 2. Payer source drives authorizations and scheduling, except for life-threatening crises. 3. Move as many non-billable (non-revenue generating) data-gathering processes as possible off staff who can bill (generate revenue). 4. Do no more by phone than is required, if the activity is billable face-to-face. 5. Automate everything that will maximize efficiency. 6. Maximize revenue (and cash flow). 7. CEOs will fully support moving electronic with all staff and contractors. 8. Collect no more data than absolutely required to meet contract requirements, deliver good care, and support strategic planning. 9. We will have one, uniform medical record and general ledger numbering structure across all PIN agencies.

PIN then formed cross-agency, cross-functional groups to map out business workflows and adjust them to national best practices. Throughout this process, all discussion and decisions were vetted against the strategic goals. Having the strategic direction provided a yardstick against which to measure all suggestions and helped keep the group focused and moving forward. Through this process, PIN members quickly discovered that 90% or more of their business operations were the same and came to rapid consensus that working together would likely result in a much stronger product and implementation outcome. The PIN structure continues to garner input from their users by soliciting requests from each member's system-level administrators and through formal change-control procedures that allow PIN to collaboratively evaluate new ideas and requests for consideration by the group. PIN's Additional Successes PIN partners were able to leverage the attractiveness of collaboration to secure state and philanthropic investment of $350,000. By pooling internal resources, leveraging cross-agency teams and with their grant monies, PIN was able to contract with Qualifacts to develop a system with unparalleled functionality and automation for handling Georgia's particularly difficult managed care requirements. Throughout the implementation process, the PIN members continued to collaborate and evaluate any decision within the framework of their established strategic direction. Importantly, PIN's collaborative approach expanded to include Qualifacts project management, business analyst, development and executive leadership as true partners toward a successful outcome. PIN's executive and project management resources worked tirelessly throughout the process to ensure that the system would exceed user expectations and be a conduit for the improvement of client care as well as business operations. PIN's success and elegant design work was attractive to a fourth Community Service Board - Advantage Behavioral Health of Athens, Georgia. Advantage recognized the high degree of forethought and work that

Integrated EHR Systems for

Multi-Agency Consortiums © 2009 Qualifacts Systems, Inc. All rights reserved

What is unique about EMR software for Consortiums? - 6

went into the creation of the PIN system and knew that by joining PIN the likelihood of a successful EHR implementation was much greater than could be realized as an independent agency. PIN's painstaking preparation, incredible attention to detail and excellent leadership made `go-live' on the new system almost a non-event. The constant collaboration between members and dedication to a singular vision ensured that the deployment of Qualifacts' CareLogic to the line users was essentially non-disruptive. This was aided by the user-friendly architecture of Qualifacts' CareLogic software product. Though no implementation is glitchless, PIN simply continued its calm, collaborative, solution-focused approach with Qualifacts as a partner to work through arising issues. Post-implementation, PIN members continue to collaborate to ensure the system remains state-of-the-art. Payer and regulatory changes, enhancements and shared best practice are all part of PIN's ongoing disciplined approach to managing their EHR service. An added benefit of the PIN partnership is that costs of changes and enhancements are split among the members.

What is unique about EMR software for Consortiums?

The Creation of Logical Companies Within a Single "Instance" For consortiums desiring to reduce administrative and support costs yet simultaneously operate as distinct organizations with respect to information security and compliance, it is essential to find a software system that allows the creation of multiple companies within a single instance of the application without separate licenses and databases. The Need for Centralized Administration The software system must be able to support centralized administration and consolidated reporting across all agencies, regions, locations and programs within the consortium. Consolidated Reporting

A single behavioral health organization faces complex reporting requirements. Consortiums require sophisticated reporting capabilities that enable individual agencies to run reports throughout the organization's hierarchy. This means having real-time access to clinical and financial data for every business entity and every program. While this functionality involves great expense and complexity in conventional on-premise software, it is a standard feature of a well-architected SaaS (software as a service) application. Widespread Delivery Models Consortiums tend to have a large geographic footprint that requires an EHR delivery model that permits users to securely work outside corporate facilities. Qualifacts' CareLogic application has the advantage of being `webnative' which means that users can access CareLogic via an encrypted connection through simple internet and web browser access. CareLogic was specifically designed to easily transmit over the web so that users experience a satisfactory response time without `super-fast' internet connectivity. Additionally, unlike many products that were originally designed as heavy client server applications, Qualifacts' CareLogic does not require the use of expensive and slow terminal services, VPN or other software add-ons. Scalability--Pay-As-You-Go Multi-agency consortiums want software that accommodates current staff size without paying for future needs at project onset. Yet they must also select software that can easily and cost-effectively be expanded as they grow, especially a consortium like PIN that desires to add new member agencies over time. A subscription-based approach to buying software helps agencies avoid having to manage increasing or replacing aging storage,

Integrated EHR Systems for

Multi-Agency Consortiums © 2009 Qualifacts Systems, Inc. All rights reserved

What is unique about EMR software for Consortiums? - 7

servers and licenses. This approach also allows member agencies to use their capital for staff and other resources to serve clients. Software developed on proprietary or outdated platforms are difficult to scale cost effectively. Qualifacts runs on Oracle and the application is hosted in a SAS70 Type II Certified data center with N+1 redundant infrastructure. This means both the software and its environment can easily handle rapid changes in the number of users

Shared and Separate Functionality Perhaps the most important feature of a software system for a consortium is that the software enables some functionality to be shared so that it is common across all members. This functionality results in a significant cost-benefit for the consortium as the system is configured only once while the initial setup cost is shared by all members. Examples of this configuration include: procedure (HCPCS) codes and insurance plan information. A software system suitable for consortiums must also enable some functionality to be used at the option of or only by an individual member. This separation may be driven by the individual needs of the consortium members, or confidentiality requirements. The configuration of this information is distinct to each agency, and the actual cost is based on the needs of that agency. Examples of this configuration include: EDIrelated codes for insurance plans, contracted rates for insurance plans, and mapping appropriate services to programs and/or clinics. Hierarchical Organization Capability (nTier) n-Tier functionality is the backbone of CareLogic. What does n-Tier mean? First, the "n" has been taken from mathematics where the letter "n" stands for any number. The "Tier" means layers ­ specifically layers within an organization's structure. So, the combined "n-Tier" means any number of layers within an organizational structure. Some examples of organizational structures that can be supported are: · · · Single organization with one clinic. Single organization with multiple clinics. Multiple organizations ­ with each organization having multiple clinics.

With n-Tier, CareLogic can meet the needs of a consortium­ allowing configurations to be shared across members or to be separated by member. At the same time, implementation time and cost for new members of a consortium are significantly reduced as the founding members have already established the `backbone' specific to all agencies' business requirements. For new members, new "branches" are simply added to the existing "consortium tree", so that the configuration that is shared will only need to be verified, not redone. The only cost incurred as the result of the new "branch" or agency is the configuration that is specific to a new member of the consortium. This feature is particularly important for tightly integrated consortiums or consortiums with shared administrative functionality. Individual members of the consortium use n-Tier functionality to ensure that their organizational structure is reflected in the application. This allows reporting, functionality, and privileging to be configured at any level within the organizational structure. As the organizational structure changes, the n-Tier structure in CareLogic can also change.

Integrated EHR Systems for

Multi-Agency Consortiums © 2009 Qualifacts Systems, Inc. All rights reserved

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Conclusion

Consortiums are a growing trend. Progressive organizations are working together to collaborate and pool resources to implement systems and achieve results that they could not realize independently. Qualifacts has seen first-hand the tremendous accomplishments by its consortium customers like PIN. CareLogic elegantly meets all the system architecture requirements for consortiums and SaaS delivery gives customers incredible capabilities without the complexities and expense of setting up, running and maintaining on-premise software systems. Qualifacts is the natural choice for consortium organizations. With the right consulting partner to guide agencies through the process, this approach helps ensure EHR project success.

About Qualifacts Systems, Inc.

Qualifacts began in the 1980s as the internal IT department of a large national behavioral healthcare company that developed the initial Qualifacts information system. By the late 1990s, it had developed into an enterprise-wide, web-based information management system. Taking note of this success, outside agencies asked whether it was available for their use and if it could be expanded for use in health and human services (HHS) organizations. In response, Qualifacts Systems was incorporated in 2000 in Nashville, Tennessee, as a separate, privately-owned software company.

Integrated EHR Systems for

Multi-Agency Consortiums © 2009 Qualifacts Systems, Inc. All rights reserved

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