Health Information Technology and Electronic Health Records Task Force

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h Information Technology and Electronic Health Records Task Force

HIT/EHR Task Force Background

In October of 2009, the ASPS Board created the HIT/EHR Task Force. The Task Force was charged with conducting an assessment of the landscape of HIT and its impact on plastic surgery. In particular, the Task Force examined the current utilization of HIT/EHRs by plastic surgeons and worked to identify the existing and emerging HIT/EHR vendors in the plastic surgery space. In order to meet the aforementioned objectives the Task Force developed the ASPS HIT/EHR member survey. The survey was designed to provide an assessment of plastic surgeons’ current usage of and desires for HIT/EHR systems and was sent in June via e-mail to a random sample of 1,000 members in solo and solo practice-shared facility, small group, large group, medium multi-specialty, and large multi-specialty practices. The Task Force decided not to survey ASPS members in academic or military practice because their use of an EHR system is typically designated by the medical facility they are employed by or the government. There were 111 responses received for a response rate of 11%.

Using information gathered from the member survey, the Task Force also developed a vendor survey. The purpose of the EHR vendor survey was to garner information on the current vendors in the plastic surgery space; specifically, what they can offer to a plastic surgeon’s practice. The vendor survey was sent to 10 HIT/EHR vendors including, but not limited to, Allscripts, Cerner, GE Healthcare, NexTech, and Athenahealth. The 10 vendors were selected because they have agreed to meet the Centers for Medicare and Medicaid Services (CMS) meaningful use criteria and currently have plastic surgery products. The survey closed on August 26, and seven responses were received.

Current Health Information Technology Environment

As HIT has continued to evolve, a growing number of medical practices are investing in EHRs. However, plastic surgeons remain behind the trend. In fact, the ASPS HIT/EHR Task Force member survey conducted in June 2010 showed that 49 percent of plastic surgeons surveyed had not even considered implementing an EHR system in the near future.

As a result of the Health Information Technology for Economic and Clinical Health Act (HITECH) industry wide adoption of EHRs is moving closer to fruition. The HITECH Act provides immediate funding for HIT infrastructure, training, dissemination of best practices, telemedicine, inclusion of HIT in clinical education, and State grants. In addition, the legislation provides significant financial incentives through the Medicare and Medicaid programs to

encourage doctors to adopt and use certified EHR. Physicians will be eligible for $40,000 to $65,000 for showing that they are meaningfully using HIT, such as through the reporting of quality measures. Hospitals will be eligible for several million dollars in the Medicaid and Medicare programs to use health information technology. Incentive payments for physicians and hospitals will continue for several years, but are phased out over time. Eventually, Medicare proposes to initiate penalties for physicians that do not use an interoperable certified EHR.

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Plastic surgeons have been slow to adopt HIT into their practices and they appear unprepared for the changes on the horizon. Sixty percent of ASPS members surveyed by the HIT/EMR Task Force said they had never used an EHR system. Given the HITECH initiative and the dramatic changes occurring in the physician practice environment there is much to think about when it comes to purchasing and implementing an EHR. The ASPS is working to make this process easier for its members.

HIT/EHR Member Survey (Appendix A)

Of the respondents, the majority are solo practitioners (65%). Those respondents that indicated they were more heavily cosmetic focused (75%) also stated that they practiced in a large

metropolitan area (50%). The majority (60%) of respondents have never used electronic health record, practice management, or billing software at any point during residency, fellowship, or a previous job. Of those surveyed 51 percent do not currently use an electronic health record in their practice. Twenty-three percent do not currently use any practice management software and 24 percent do not use any billing software. Nearly half (49%) of respondents said they are not considering implementing any electronic health record, practice management, or billing software in the near future. However, more than half (51%) of those surveyed stated that they are

considering the implementation of electronic health record, practice management, or billing software in the next couple of years.

Of the 49 percent of respondents who stated they currently use electronic health records, 19 percent are currently using the NexTech product. Of those surveyed, 77 percent are currently using practice management software in their practice; the majority (25%) is using the NexTech product. Seventy-six percent of respondents stated they are currently using billing software in their practice. Of those that stated they are currently using billing software 21 percent said they are using the NexTech product. Seventy percent of respondents who use EHRs indicated that they are satisfied with their current EHR system. However, many went on to say “the system does what I need it to do, but it is far from ideal.” Furthermore, 42 percent of respondents who use EHRs stated they would consider updating their current EHR software.

On average, respondents believed that the five most important functions of an EHR system were computerized physician order entry (CPOE), web-based system (cloud computing), patient web portal, the ability to check or advise on evaluation and management coding levels based on fields entered, and ability to use a tablet in the office. Eighty-one percent of respondents indicated initial training as the most important type of support; followed by phone (73%), screen sharing (69%), and periodic updates (67%). Seventy-five percent of respondents do not have multiple office locations. Nevertheless, of those that responded 6 percent anticipate needing only 1 workstation, 43 percent 2-5 workstations, 36 percent 6-10 workstations, 9 percent 11-15 workstations, and 4 percent more than 15 workstations. Respondents considered about seven days a reasonable amount of time to spend on staff training. When asked how much they would be willing to pay to install or upgrade an electronic health record or practice management system the responses ranged from $0-$100,000; averaging at about $15,662. In regard to how much respondents would be willing to pay for annual updates and maintenance responses ranged from

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$0-$10,000; averaging at about $1,804. For additional tech support respondents stated they would be willing to pay $0-$3,000; averaging at about $528.

HIT/EHR Vendor Survey (Appendix B)

With EHR adoption in the United States still in its early stages, there is still time for plastic surgeons to get education, purchase, and implement an EHR system. Furthermore, with 51 percent of plastic surgeons not currently using an EHR system, plastic surgery remains an untapped market. The seven vendors (Cosmetisuite/Meditab, eClinicalworks, e-MDs, Cerner, NextTech, GE Healthcare, and NextGen) that completed the survey showed a great amount of interest in collaborating with the ASPS to help its members get educated on, purchase, and implement an EHR system that will best fit their practice needs.

The comparison chart below has been developed to provide a roadmap for selecting and

purchasing the most appropriate EHR system for the user’s practice. The vendors are organized based on the number of providers they are currently servicing, ranging from 68,000 – 2,800. However, charts do not have the capacity to capture all data. Thus, a summary of the vendors who participated in the survey, attributes including but not limited to how long the company has been in business, how many providers it currently serves, and how maintenance and upgrades are handled is provided.

Regarding pricing, although the survey asked for detailed pricing information, not all of the vendors provided actual or estimated cost information. The vendors that did provide estimated cost information (Cosmetisuite, e-MD, and GE Healthcare) have a discussion of cost in their summary sections. The Task Force realizes this is a significant gap in the report where further research needs to be done (e.g., through the RFP process). We believe that the information provided will serve as a valuable starting point for our members to assist in determining which vendors might have products worthy of their consideration.

GE Healthcare

GE Healthcare (Centricity Advance) has been in business for 83 years; providing service to 2,000 physician offices and 68,000 providers. The company has offered the EHR, practice management, and billing product for more than six years. The product licenses are issued per billable provider and its products operate on the SQL Database and Microsoft Small Business Server with Windows 2003 or greater. The monthly subscription is $595 per provider with no annual commitment. There is also no long-term buyout. Subscriptions include an integrated practice management, EHR, patient portal, CPOE, and billing database. The subscription cost also includes software, maintenance, and upgrades. An additional training package can be purchased at $6,500 per provider and an Adoption Assurance Program can be purchased for an additional $1,500 annual per provider fee. GE stated an interest in working with ASPS to develop enhancements for our members. GE also expressed an interest in providing educational webinars on meaningful use and its value to plastic surgeons. As part of the data hosting GE has implemented a disaster recovery and data-recovery process to eliminate unplanned downtime and system failures. If the contract is terminated the user owns all the data and will have access to the data at any time.

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As part of the photo archiving software users can import a photo of the patient into the practice management side of the solution. Photos can also be uploaded via digital camera, USB, or from a file. Centricity Advance can interface with payment processing systems as long as they communicate via HL-7 standard interface. Although Centricity is a fully integrated practice management, EHR, and patient portal solution, it can interface with all systems that

communicate via HL-7 standard interface. Custom lab interface development is between $1250 and $5000 per interface. Centricity has direct connectivity with Emdeon, Availity, Mckesson, ProxyMed, BCBS, Exchange EDI, and Medicare clearinghouses at no additional cost to the user. NextGen

For 20 years NextGen has been providing service to 3,000 physician practices and over 55,000 providers. It has offered its EHR, practice management, and billing products for 15 years. NextGen issues licenses by provider and operates on the Microsoft platform. The overall cost of the product depends on the delivery method and includes software and hardware. On-going maintenance and upgrades cost 19 percent of the software price. Enhancement updates are submitted by the client and NextGen responds to all of the submissions. To help safeguard against unplanned downtime, fail over functions are available. System failures are fixed immediately. If the contract is terminated the user is responsible for the cost of data

conversion/un-encryption. NextGen’s software is capable of interfacing with Transfirst and Instamed payment processing systems at an additional cost to the user. In addition, the software can interface with practice management, lab, and outcomes database software at an additional cost to the user. Most clearinghouses can also be interfaced with NextGen. The company does not mandate any in particular and additional cost is dependent on the clearinghouse.

eClinicalworks

For over 10 years eClinicalworks has provided more than 7,500 physician practices and

approximately 40,000 providers with service. It has offered an EHR, practice management, and billing system for over 10 years. Licenses are issued on a perpetual basis based on full-time employee count. The system runs on the Windows or MAC network. Overall costs are based on practice needs and include software, training, maintenance, upgrades, and employee travel. Enhancement requests are accepted through the user’s personal portal (eCWideas). From there the user can add suggestions as well as vote on enhancement submissions made by other users. If a system fails eClinicalworks considers this a level 3 issue that receives immediate attention from customer service. Photo archiving is included in the software by scanning and

electronically adding to files. Interfacing with payment processing, practice management, and lab software is available at an additional cost to the user. Additionally, the software can interface with over 60 Clearinghouses.

Cerner

Cerner has been in business for 31 years providing service to 3,400 physician practices and 30,000 providers. The EHR product has only been offered for 13 years; however, the practice management and billing products have been offered for 20 years. Cerner issues licenses per

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provider, per month and the cost is a monthly subscription that includes on-going support, maintenance and upgrades. The system operates on both Server 2003 and 2008 operating platforms. The overall cost of the system varies on the package and includes software, training, maintenance, and upgrades. Application enhancements that have been requested by clients, that require modifications to the Cerner source code are evaluated as to their appropriateness, and if implemented, are applied to the code that is in general released and made available to all clients. Cerner prides itself on having a 99.9% uptime. In the case of system failure, all data is housed in Cerner's data center, a 71,000-square foot, dual-fed, redundant data center operation located in Lee’s Summit, Missouri, a suburb of Kansas City. Its hardware is housed in a tornado-proof building and the facility is designed to eliminate client downtime by providing uninterrupted power and facility operations. The data center is staffed and managed 24 hours a day, 7 days a week, 365 days a year. In the event of contract termination, the user pays for conversion/un-encryption of the data. Cerner products can interface with all HL-7 compliant systems for an additional fee. The software interfaces with the Relay Health Clearinghouse at no additional cost.

e-MD

For the last 14 years e-MD has provided service for over 2,500 physician offices and more than 6,800 providers. The EHR system has been available for over 11 years and the practice

management and billing systems for over 17 years. The system licenses are issued by provider and the system is a single integrated solution that runs on Microsoft SQL Server 2008. The cost for the first EHR only provider is approximately $10,000-$12,000; integrated EHR/practice management $13,000-$17,000. Overall costs are based on practice needs and include software, training, maintenance, upgrades, and employee travel. On-going maintenance and upgrades cost 22 percent of the licensing fees. Enhancement requests are submitted through the customer support portal which is monitored by e-MD. Numerous best practices are in place for disaster recovery and significant resources are applied to eliminate software problems during the development, testing, and beta phases of implementation. If the contract is terminated the user has full access to their database.

The software allows photo archiving; the document management capabilities include the ability to add and annotate photos within notes, as well as capture (camera, import, scan) any other kind of document. The software does not currently interface with a payment processing system. Additionally, e-MD’s billing software is integrated as part of the EHR/PM Solution Series. The cost for a fully integrated system is relatively low compared to the purchase of e-MD’s EHR only. However, e-MDs can also interface using HL-7 interfacing standards. Pricing for this is based upon the level of interface (e.g. bi-directional, demographics/appointments/charges, etc.) as well as what the other party may charge. The software can interface with Navicure,

GatewayEDI, Ingenix, RelayHealth, or Availity. The system also has the potential to interface with almost all clearinghouses with no extra programming required, but at an additional cost to the user.

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NexTech services 1,905 physician practices and 3,000 providers and has been in business for over 14 years. The EHR product has been offered for six years; however, the practice

management and billing products have been offered for 14 years. Licenses are issued per provider per workstation. The database engine is currently deployed on IBM AIX and HP’s OpenVMS operating system. The overall cost of the system varies on the package and includes software, training, maintenance, and upgrades. A proactive enhancement process is in place that includes gathering client feedback requests on a regular basis and having them ready for

implementation in future releases. Backups are in place to help prevent unplanned downtime and if the system fails it is fixed immediately.

NexTech’s photo archiving simplifies the process of taking, saving, editing and retrieving patient photographs. It also captures images directly from digital cameras for quick image manipulation functionality. The software provides before and after photo overlay, one-touch photograph downloading, and multi-image viewing and print capabilities. The user can also auto-export to Microsoft PowerPoint and quickly find images based on procedures, categories, custom tags, and more with the advanced search engine. The NexTech product interfaces with Chase Paymentech payment processor, HL-7 compliant lab systems, and outcomes databases at no additional cost to the user. However, there is an additional cost to the user for interface with practice management systems and clearinghouses (Gateway EDI and ECP).

Cosmetisuite/Meditab

Cosmetisuite/Meditab has been in business for 12 years. The company is currently servicing 1,100 physician practices and 2,800 providers. It has offered an EHR system for over seven years; practice management and billing systems for over 11 years. The products are licensed by provider (i.e. provider, NP, and PA) and operate on the Windows network. Cosmetisuite

estimates the cost of its entire package at $12,000-$18,000, with yearly maintenance billed separately at about $3 thousand per year including updates and upgrades. Enhancement requests are available with next version upgrade or update. Unplanned downtime is prevented by making backup available for installation on any local machine that temporarily acts as a server.

Depending on the type and size of the data service can be restored in 1-2 hours. All update and maintenance problems are rectified in 4-24 hours. Each user’s contract is different, thus, each user will have different fees for conversion of data to another system if the contract is

terminated.

The software allows photo archiving that is tagged by procedure, view, and/or sequence. It can be exported to common image formats and combined in groups for printing before and after pictures. It can also be imported, included in visit notes, and can be queried by any of the aforementioned properties. The software also allows interfacing with any payment processing and practice management software and clearinghouses at no additional cost to the user. However, Cosmetisuite suggests ENS Health as the payment processor and Availity, because they have a direct relationship with them for eligibility checking and auto posting of payment.

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Page | 7 Common Vendor Attributes

In surveying the vendors we required that they guarantee compliance with federal and state mandates and with the HIPAA and Security Rule and that their software would meet

"meaningful use" criteria. In reviewing the survey data a number of common characteristics presented themselves including the ability to use the software with a desktop PC and a tablet. In addition, all of the vendors said their software allows the user to easily customize templates, determine which item(s) should automatically transfer over from previous visits and create default notes that they can copy, and allows the patient to submit a digital signature. To ease the work of the user all of the vendors stated that their software is capable of automating prescription orders, lab and diagnostic orders, provider alerts, patient education, and referral requests based on EHR entries (e.g. allergies or missing tests or labs). All of the systems also allow importing of lab or radiology reports, photo and x-ray image archiving, and storing photos in the body of notes. Additionally, all of the companies stated that their software allows the user to choose CPT codes from a pull-down screen, automate alerts based on insurance plans and CPT codes, bill independently under separate Tax ID's, and track claims rejections and write-offs. All of the companies’ software allows the performance of batch eligibility checks, automation of 2nd and 3rd insurance billing, and multiple fee schedules based on provider, location, and date ranges. Other commonalities among the vendors include customization of reports for aging accounts (i.e. A/R), scheduling more than one patient in a slot, scheduling for multiple

offices/physicians/practitioners (e.g. PA, NP, or nurse injectors), and designation of patient rooms. Other key aspects of all the software products are the capability to access and input data via the web securely via remote computer, data entry via voice (e.g. Dragon), and interfacing with practice management and lab system, and clearinghouses. All of the vendors stated that software and training were included in the overall package price of the software. Finally, it is important to note that all of the vendors are capable of providing what our survey respondents suggested were the five most important functions of an EHR system: computerized physician order entry (CPOE), web-based system (cloud computing), patient web portal, the ability to check or advise on evaluation and management coding levels based on fields entered, and ability to use a tablet in the office.

Conclusions

Clearly there are a lot of options for EHR systems, and ASPS cannot make a definitive

recommendation for any particular practice given the wide range of practice variables. However, after examining the current landscape of HIT and its impact on plastic surgery the Task Force recommends the following:

• Further education of ASPS members so that they understand the value of implementing

an EHR system. The Task Force sponsored an EHR Roundtable in Toronto. The findings of the Task Force could be published in PSN along with an additional

educational article or series of articles on specific EHR topics (e.g., tips for selecting a vendor). The final Task Force Report and comparison chart can be posted on

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also collaborate with interested vendors on educational webinars to help educate members.

• Conduct a more in-depth review of the vendors that participated in the survey via an RFP

to better substantiate the findings and distinguish between the baseline features offered.

• An EHR Workgroup is being formed to explore a potential formal business relationship

with one or more vendors.

• Have legal counsel review the final report before publication.

HIT/EHR Task Force Members:

Malcolm Z. Roth, MD, Chair Paul S. Cederna, MD Michael C. Edwards, MD Bahman Guyuron, MD Scott E. Kasden, MD Geoffrey R. Keyes, MD Lynn L. C. Jeffers, MD Robert X. Murphy, MD Rachel A. Rutolo, MD Loren S. Schechter, MD Robert A. Weber, MD Andrew M. Wexler, MD

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Page | 9 HIT/EHR Vendor Contact Information

Name NameName

Name CompanyCompanyCompany Company AddressAddressAddressAddress City/Town:City/Town: City/Town:City/Town: StateStateStateState Email AddressEmail AddressEmail AddressEmail Address Phone Phone Phone Phone Number: Number: Number: Number: Mike Swim NextGen

Healthcare Atlanta GA mswim@nextgen.com 215-385-7630 Andrew Johnson GE Healthcare 3135 Easton Turnpike Fairfield CT andrew.t.johnson@ge.com 262-290-8597 Christina Majeed NexTech 5550 W. Executive

Drive Suite 350 Tampa

FL

c.majeed@nextech.com 800-490-0821 Aby Mathew

Cerner Corporation 2800 Rockcreek

Parkway Kansas City

MO

aby.mathew@cerner.com 816-201-7396 Patrick Hall e-MDs 9900 Spectrum Drive Austin TX phall@e-mds.com 512.638.6966 Jennifer Lewis Allscripts 8529 Six Forks Road Raleigh NC jen.lewis@allscripts.com 919-609-4545 Scott Bramhall

eClinicalworks 112 Turnpike Road

(Route 9) Westborough MA

scott.bramhall@eclinicalworks.com 925-699-1440 Kunal Shah Cosmetisuite /

Meditab Software Inc 333 Hegenberger Rd Suite 800 Oakland CA kunals@meditab.com 510-913-3969

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Comparison Chart

HIT/EHR Vendors

GE Healthcare NextGen eClinicalworks Cerner e-MDs NexTech Cosmetisuite/Meditab

General

The company has an EHR system geared

toward plastic surgeons

X

The company has a practice management

system geared toward plastic surgeons

X

The company has a billing system geared

toward plastic surgeons

X

The software is guaranteed to comply with all federal and state mandates and with the HIPAA and Security Rule

X

The software is guaranteed to meet

"meaningful use" criteria

X

The software is CCHIT certified

X

The software is sold in modules

_X

The software has to be purchased as a

complete package

X

Functions/modules can be added as

needed

X

There is not an additional cost for

implementing the operating platform

X

The software can be used with a desktop

PC

X

The software can be used with a tablet

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HIT/EHR Vendors

The software can be used with a MAC

X

The software can be used with a iPad

_X

Workflow

User can easily customize templates

_X

User can determine which item(s) should automatically transfer over from previous visits

X

User can default notes that they can copy

from

X

The user can drag and drop documents if

available in electronic form

X

The user can verify demographics and insurance eligibility, collect co-pays, and complete automated forms from a single window

X

The patients can check-in using a kiosk

_X

The software allows patient to submit a

digital signature

X

The software allows the user to automate

prescription orders based on EHR entries

X

The software allows the user to automate lab and diagnostic orders based on EHR entries

X

The software allows the user to automate provider alerts based on EHR entries (e.g. allergies or missing tests or labs)

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HIT/EHR Vendors

patient education based on EHR entries

X

referral request based on EHR entries

X

inventory tracking based on EHR entries

X

The software allows automatic importing

of lab or radiology reports

X

The software allows photo archiving

X

The software allows patient to submit

photos online

X

The software allows x-ray image archiving

_X

The software allows user to morph

photos

X

The software allows user to store photos

in the body of notes

X

Billing

The software allows user to generate quotes that include several permutations and/or discounts or specials

X

The software allows user to bill

independently under separate Tax ID's

X

The software allows user to create their

own codes (e.g. cosmetic codes)

X

The software allows user to choose CPT

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HIT/EHR Vendors

Billers can see all pending visits that have

to be billed

X

Billers can automate alerts based on

insurance plans and CPT codes

X

2nd and 3rd insurance billing

X

Billers can auto-populate based on

electronic superbills

X

Billers can perform batch eligibility

checks

X

Billers can track claims rejections and

write-offs

X

The software allows users to customize

reports for aging accounts (i.e. A/R)

X

Billers can create multiple fee schedules based on provider, location, and date ranges

X

Scheduling

The software allows user to schedule

more than one patient in a slot

X

The software allows user to create schedules for multiple

offices/physicians/practitioners (e.g. PA, NP, or nurse injectors)

X

The software allows user to designate

patient rooms

X

Interface

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HIT/EHR Vendors

iPhone

X

iPad

_X

Calendar

X

Interoffice messaging

_X

Patient data

_X

The software has the capabilities to access and input data via the web securely:

Remote computer

X

Phone/handheld device

_X

The software allows user to enter data via:

Templates

X

Macros

_X

Voice (e.g. Dragon)

X

Transcription service

X

Handwriting recognition

_X

The software allows user to use a tablet to have the patient sign forms directly on the screen

X

The software can interface with a payment processing system (e.g. Solveras, Chase paymentech, or Bank of America)