This document discusses Community Health Connections' implementation of an electronic health record system. It provides an overview of the organization and outlines their plan to implement OpenVista EHR software across three clinics by February 2011. It describes the anticipated benefits of EHR including reduced errors, improved workflows and access to patient information. The implementation plan includes teams for project management, hardware, software and stakeholders. It also covers training, data migration, technical infrastructure including servers and network upgrades, meeting meaningful use requirements and realizing financial benefits and savings.

1. Community Health Connections Electronic Health Records (EHR) Implementation

2. Panel 1 – Introduction 2

3. Implementación del Sistéma de Records Médico ElectrónicoImplementing EHR Beneficios en la implementación del EHR Los costos administrativos generales pueden reducirse, Los errores de datos puede reducirse, y Los resultados adversos pueden ser más rápidamente identificados 3

4. CHC Story Founded 30 years Federally Qualified Health Center 3 Clinics Providing Adult Medicine, Women’s Health, Mental Health & Pediatric services Mobile clinic for school programs Laboratory (LAB), Pharmacy (PHM) & Radiology (RAD) at the 3 clinics $1.6 million grant to implement & EHR & meet MU 4

5. EHR Benefits Decreased charting/prescribing errors Improved work-flow Immediate access to Radiology Lab results Patient charts More satisfying work conditions for our employees Freeing up space now used to store charts 5

6. Central Clinic Layout 6

7. West/East Clinic Layout 7

8. Scope & Deliverables Develop Plan to install EHR System Must meet meaningful use Capable of information exchange with National Health Information Network (NHIN) Use OpenVista Realistic plan ready for review on 3/25/2010 Final Deliverables Detailed Implementation Plan with narrative & supporting documents Presentation of Implementation Plan for the Review Committee 8

9. Critical Success Factors Full C-suite support Clinical champion - Chief Medical Officer will lead the Implementation project EHR is a clinical project Organization is stable with quality improvement in place We will achieve a positive return on investment in an EHR 9

10. Assumptions & Constraints Implementation project to begin March 30, 2010, clinic-by-clinic, using Plan Do Study Act (PDSA) process, & completed by February 2011 CHC is compliant with Federal & State regulations, including meaningful use CONNECT Gateway will be used for patient access, Uniform Data System (UDS) reporting & updating the County Immunization Registry Existing use of the Patient Electronic Care System (PECS) registry will migrate to the EHR 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 10

11. Project Management Office 11

12. Process Team 12

13. Hardware Team 13

14. Software Team 14

15. Stakeholders Management Board, Steering committee, Chief Medical Officer Implementation team PM, Application & clinical specialist, process analysts & Consultants IT Team Integration Architect, DB, Networking, System Admin, Application Development Functional Departments Clinical Team, Billing, Training, Medical records, quality, Pharmacy, Radiology & Libratory departments External Patients, insurance companies, community volunteers, media, Medsphere, government agencies; HHS, NHIN….. 15

16. Communication Plan Purpose Vision What could happen Communication Methods 16

17. Communication Plan -Accountability 17

18. Compliance 18

19. Regulations CMS - Security/HIPAA Strong organization culture of security: Documented processes to protect ePHI Confidentiality, availability, integrity Training All individuals are personally responsible with severe penalties Roll-out, new hire training, refresher training Real-life case discussions in monthly department meetings Top management priority Talked about often Known organizational auditing 19

20. Security Standards Administrative Security Officer ultimate responsibility Risk Analysis required Roles & privileges process including termination Business relationships Physical Facility controls Media access Workstation access Technical Audits Access control Transmission, firewall, virus security Remote access 20

21. Risk Analysis Methodology Full analysis in Implementation Plan Higher Risk Areas Poor adoption rates Process improvements required Inappropriately used ePHI data Disaster recovery plans 21

22. Current System State 22

23. Future System State 23

24. Medsphere OpenVista EHR Software: OpenVista Leverage billions of dollars of VA software development Open source fosters software enhancements Close relationship with government officials for meaningful use Local company resources Medshpere management understands “open source“ Track Record Hundreds of reference sites including ambulatory sites Proven & quick Stage 6 implementations 24

25. Implementation Schedule 25

26. Panel 2 - Workflow 26

27. Process Workflow PatientCare &HealthRecords PatientRegistration & Scheduling Billing& Payment 27

30. Clinical Decision Support Tools ORDER SET 30

32. Improve quality of care

33. Identify drug-drug interactions

34. Identify drug allergies

35. Increase patient compliance

36. Improve patient self-care

37. Meet Meaningful Use31

39. Ability to abstract data for research 32

41. Diabetes

42. Hypertension

43. WOMEN

44. Initial History & Physical Exam

45. Trimester Assessments

46. PEDIATRICS

47. Preventive Health

48. Upper Respiratory Infection33

50. Asthma

51. Obesity

52. WOMEN

53. Prenatal: blood pressure, fetal heart tones, etc.

54. Preventive Care

55. PEDIATRICS

56. Age-Specific: body measurements, immunizations, developmental milestones 34

58. Timely access to current:

59. Medications

60. Lab results

62. Prescription refill requests35

64. Learn the application

69. Patient wait times

70. Percentage of physician CPOE utilization

71. Meet Meaningful Use criteria37

73. New online kiosk option38

74. Financial Process/Workflow Front & Back Office Workflow Coordination Interoperability / Coding & Billing Integration Documentation Payer-specific Requirements Processes E&M Calculator at point of care Data flow from system to system 39

77. Data Migration Strategy The Challenge Pre-populate the EHRwith useful data day 1 145,000 annualpatient visits Over 30+ years to be scanned & abstracted 41

78. Data Migration Strategy Solution for Existing Electronic Data Mirth Connect integration engine to develop channels between old & new databases Automate on-going data transfers: Updates, additions & deletions Solution for Paper Records Pre-Rollout: Migrate records of patients most likely to be seen soon Post-Rollout: Migrate records on a “go-forward” basis – patient who make appointments or appear at the clinic 42

79. Data Migration Table 43

80. Panel 3 - Hardware Operation Environment 44

81. Implementation Strategy Current environment Network, Servers/Storage Applications, operations Upgrade plans Upgraded technical architecture Fiber Ring network Thin client deployments 45

82. Technical Architecture 46

83. Fiber Ring Topology Current T-1 connectivity Legacy copper connectivity at 1.544 MPS Fiber Ring Topology Providers: AT&T & Cox communications Why Cox Supporting Health Care providers Discussion of data/fact gathering with Sharp IT, & Family Health IT Fiber connectivity redundancy Dual connectivity from each router to Fiber ring Access & Security-High Level Patient/PHR-Web Portal IT support & Physician VPN & RSA/Token security 47

84. 48

85. Server Hardware - Location & Features Location Store in special server rooms, Central & East clinic (backup) Server Rooms Features Secure entrance Temperature controlled Redundant Power w/ Spike & Surge protection Monitoring – cameras, sensors Qualified staffs Server Hardware Features Intel Xeon processor – multiple processor RAID with hot swappable HD Redundant connections – multiple Ethernet / fiber ports Tape backup system 49

86. Server Software - Operating &Application Windows server 2008/R2 Standard, business,data center Features of server Operating Systems Robust – even during hardware failure Multiple security features including firewalls & intrusion detection Remote administration Extensive audit trail Special features of application servers & database Cache Clustering Virtualization (VMware) for development, demo, training, & QA Terminal services 50

87. Failover Clustering Key Benefits Protects against data loss& service interruptions Automates failover to reduced downtime, lower complexity of disaster recovery plan Reduces administrative overhead by automatically synchronize application & cluster changes, easier tokeep consistent than unclustered servers Updating server without service interruption 51

88. Multi-site Clustering Key Benefits Protects against loss of an entire datacenter such as power outage, fire, hurricanes, floods, earthquakes, terrorisms Automates failover to reduced downtime, lower complexity of disaster recovery plan Reduces administrative overheadby automatically synchronize application & cluster changes, easier to keep consistent than unclustered servers Updating server without service interruption 52

89. Terminal Services Benefits Windows Server 2008/R2 Terminal Services gateway enables the creation of a scalable SSL-based remote access solution Terminal Services Session Broker enable the creation of simple & effective Load-balancing a terminal server farm 53

90. Software Installation Environments Non-production Development Quality Assurance (QA)/Test User Acceptance Testing (UAT) Demonstration Training Production 54

91. Infrastructure - Security & Privacy Password policy enhancements SSL Configuration Client Side certificates Audit Control Data Integrity HIPAA Compliant VPN Access – Two Factor Authentication (RSA Token) 55

92. Remote Access Provider can access EMR using VPNover the Internet 56

93. Workstation & Peripherals Thin Client Stations Work Stations Laptops Monitors Carts Printers All-in-Ones Peripherals 57

94. Computer Operations Service Support Service Desk Incident Management Client Surveys Service Delivery Service Level Management Service Level Agreements Production Review Board 58

95. Panel 4 - Software Aspects 59

96. Current System State 60

97. Future System State 61

98. Current Data Flow State 62

99. Future Data Flow State 63

100. OpenVista Install OpenVista & InterSystems Cache Convert & migrate sample patientdata from PMS to OpenVista Support clinical team in system configuration tasks Test activated features of OpenVista& interface connections Test Health Information Exchange (HIE) connections... 64

101. InterSystems Cache OpenVista Database Selection InterSystems Cache Proprietary software Extension of MUMPS Graphical User Interface (GUI) interface Window, UNIX, Linux, Mac OS X, & Open VMS server High performance object database Web gateways access to web browser interface Rapid integration & development platform GT.M Open Source MUMPS language MUMPS database Linux & Unix operating system 65

102. OpenVista Database InterSystems Cache 66

103. Interoperability - Mirth & NHIN CONNECT Add OpenVista outbound & inbound channels Admit, Discharge, Transfer, Scheduling, Financial Transaction Create new inbound & outbound channels for Order Messages (ORM) & Order Results (ORU) Create new outbound channel to National Health Information Network (NHIN) CONNECT Gateway Create inbound & outbound Continuity of Care Record (CCR) & Continuity of Care Document (CCD) Install Cache Java Database Driver for the Mirth database reader Configure NHIN gateway connector in Mirth Test & deploy changes 67

104. Software Development Implement Rapid Prototyping Fits well into PDSA philosophy Application Lifecycle Management Microsoft Team Foundation Server 2010 OpenVista Patient Portal 68

105. Configuration Management Framework Identification Control Reporting Audit Benefits of Configuration Management Legal Obligations – Meaningful Use, HIPAA Process & approach Software Configuration Management Team Foundation Server 2010 Configuration Management Database Definitive Media Library 69

106. Configuration Management Manage changes to all Configuration Items in Production Server & network components, Software programs, Signed contract documents, etc. 70

107. Downtime Procedures GOAL CHC clinics remain operational during planned or unplanned events Plan is created/approved by internal committee METHOD Use approved paper methods to maintain workflow during downtime All paper records must be “back-chartered” into the electronic record in a timely fashion BOTTOM LINE Ensure downtime episode does not pose a threat to patient safety & integrity of clinical practice 71

108. Panel 5 - UAT, Training & Go Live 72

109. User Acceptance Testing (UAT) Failure to conduct UAT will result in finding more problems after release. UAT should confirm whether the software supports the existing business process, not whether or not the software works. UAT will compare user expectation to actual results very early in the implementation. User requirements that evolve during UAT will be part of the post-EHR implementation. Key: Super-Users acceptance will influence community acceptance of the EHR. Steps for UAT Run Test Cases Mock-go Live Super-Users sign-off , Go-No Date(readiness for go-live) 73

110. Training Purpose (Why) Who, What, Where, How Effectiveness Afterwards – What’s Next 74

111. Training V1 75

112. Training V2 76

113. Project Monitoring & Control Data to be collected & reviewed during the implementation Meaningful Use Financial Return on Investment Quality Measures Compliance Patient Satisfaction Surveys Post Implementation Review Outstanding Issues Maintenance & Support 77

114. Panel 6 - Financial Impact 78

115. Meaningful Use 79

116. Meaningful Use 80

117. 81

118. Meaningful Use Stage 1 Progress to Meeting Criteria 82

119. Procurement Plan Initial Understanding: HW, SW team needs Defined process Potential suppliers Budget for investment Vendor Evaluation Scorecard Criteria & weights Technology, quality, responsiveness, delivery, business, environment RFQs Delivery without negatively impacting go-live Tracking Spending & Performance 83

120. Major Expenditures Hardware Capital Expense = $330K Servers WAN SAN Fiber ring Thin clients High speed copiers Software Capital Expense (1st year) = $ 73K Elite licensing (80 to 115 users increase over 6 years) 84

121. Timing Go-Live Oct 2010 Training Nov-Dec 2010 Savings from Implementation Mar 2011 MU payments May 2011 Increased demand During Year 2012 85

122. Benefits MU Medicaid incentives ($3.5M) One time incentive 2011-2016 Transcription savings ($29K/mo) Increased number of visits: Labor efficiencies ($38K/mo) Word of mouth Riddance of flow charts, superbills, H&Ps, etc.& other administrative costs ($5-10K/mo) Reduction of labor costs ($18K/mo) Reduction of storage expenses 86

123. Cost Drivers Anticipate loss of productivity during training& initial deployment period Hardware $330K Software $73K first year $444K over 6 years Staffing $4M over 6 years 87

124. Staffing Assumptions Temporary 2 Trainers 2 Hardware Engineer Contractors 1 Contractor – OpenVista 4 Abstractors Backfill – MDs, RNPs, Nurses Permanent 1 Process Analyst 2 Technologists 1 Meaningful Use Specialist Providers Overtime Costs PSRs during training 88

125. Cost Breakdown 89

126. Cost & Benefits 90

127. NPV Analysis 91

128. Cumulative Cash Flows 92

129. What It’s All About 93

130. Additional Questions Thank You 94

131. UCSD Extensions HIT Spring 2010 Class 95

132. UCSD Extensions HIT Spring 2010 Class 96