My name is Monique Dever. I am with Patagonia Health from the marketing executive team.
Our presenter today is Aaron Davis. Aaron is project manager for the Center of Public Health Initiatives, and he specializes in project management and strategic business operations. Aaron is a Wichita State University graduate three times over, with undergraduate degrees in business administration and integrated marketing communications, as well as a master's in business administration.
His previous work includes both government and private industry, which includes more than five years at the Sedgwick County Health Department. So without further ado, I am going to go ahead and share my screen with Aaron and he will begin his presentation.
Opening Remarks
Alright, thanks, Monique.
Okay, great. Thank you for that introduction, and thank you all for joining. My name is Aaron Davis, as Monique st two years of my life and what is quickly becoming a great passion of mine.
Before we get too far into this, there are a couple of quick things I want to cover. The first is that I work for a group called the Community Engagement Institute at Wichita State University. We have a handful of centers that work on various aspects of social-type work throughout the state. I work for the Center for Public Health Initiatives, and we work to improve the public health system in Kansas by empowering people, developing organizations and strengthening systems.
This project that I am going to be presenting on today is something that covered all three of those areas.
Because our project was funded by a grant from the CDC, I have to include this technical piece. I want to make sure you all have a chance to read this and understand that everything I express today or go over, including what you see in the slides, is not a reflection of the policies of DHHS, the CDC, the Kansas Department of Health and Environment, who received this grant, or Wichita State University. Even though we are talking through the Patagonia platform, we do not give any specific endorsements to Patagonia or other systems.
So with that, let’s go ahead and get started.
Agenda Overview
We are going to introduce you to Kansas and some of the aspects involved in this type of work here. We will go over the grant that led to this project, then talk about our EHR project, the things we learned from it, and some guidance moving forward. This guidance is targeted toward Kansas, but will apply to any health department across the country.
Kansas Context
Kansas capital is Topeka. We are talking about roughly 2.9 million people. What many do not realize is that Kansas is actually very large, over 81,000 square miles. Kansas is decentralized. When you combine size with our home rule structure, we end up with 105 counties and 100 local health departments operating independently. Everyone is out doing their own thing. Of course there is collaboration and partnerships, but compared to a centralized state health department we have a very different picture.
Most of the populations served by our local health departments are under 25,000. This graph from the 2013 national profile of local health departments from NACCHO shows that clearly. If broken down even further, Kansas would likely still be at the top. We have a lot of small communities. Another table shows the types of programs health departments cover in Kansas. Immunizations are a huge focus along with TB, blood lead screening, WIC, maternal child health programs, and others.
Out of our 100 health departments:
- Around 24 use EHRs
- 11 of those were specifically due to our pilot program
- Many health departments use a homegrown practice management system
- Some use free software or rely on paper records
- Many use paper for both health records and billing, along with online data entry
- The majority, even some with EHRs, use all of these approaches
CDC Grant Background
A couple of years ago, the CDC proposed a grant focused on immunization billing. The problem they were focusing on was that insured patients were accessing immunization services at health departments largely for free or very nominal fees. Health departments have the ability to bill insurance, but many were not doing so effectively.
The counties and health departments were essentially eating the costs. Meanwhile, insurance companies and Medicaid were not being billed for services they covered. So there was a chance for expansion of billing practices, capturing reimbursements, and increasing sustainability.
This was a national grant. In 2012 the Kansas iteration focused on planning. The Kansas Foundation for Medical Care researched how departments were billing, whether they were billing, and even attempted a pilot using certified coders. The study was somewhat inconclusive. At the time there were only two certified coders across the entire state, and now there are around four or five.
KFMC made several recommendations, and Kansas selected these three:
- Create a biller-specific coding manual
- Bring in an outside group such as AAPC for coding training
- Implement an EHR pilot program
Where other states were trying to convince health departments to begin billing, Kansas already had many billing but needed to do it more effectively and consistently.
Kansas applied for the second iteration of the grant, focused on implementation. KDHE hired our group at the Community Engagement Institute to tackle the work.
Key Definitions
When we launched this project, it became clear that many health departments in Kansas were not familiar with EHR terms. So here is a quick overview:
- Electronic Health Records (EHRs) and Electronic Medical Records: I use these interchangeably, though they are technically different
- Practice Management System: Scheduling, calendar, patient demographics
- Billing Software: Insurance information and billing details
- Hybrid Systems: Mix of the above
- EHRs: Some include all three components, some only one or two
- Outsourced Billing: Hiring a company to handle billing
- Clearinghouse: A major learning curve for us. Clearinghouses vary, have different fees, and some systems require specific ones.
Pilot Project Overview
We offered:
- Training and guidance from experienced EHR consultants
- Project management from our team
- Financial assistance up to 75 percent of system cost, capped at $10,000
- A peer learning workgroup
From our applicants, we selected 11 counties. Populations ranged from 2,500 to 35,000. Staff ranged from 1.5 to 15 employees. Billing revenue and encounter volume varied widely.
What They Signed Up For
The pilot included:
- An all-day EHR review and implementation training led by Sinnova
- Demos from about 15 vendors
- Presentations from health departments that had already implemented systems
- Weekly calls, eventually monthly and then quarterly
- Monthly reports on progress
- Surveys before, during and after implementation
Project Timeline
- March 26: All-day training
- Spring: Demos and evaluation
- Summer: Planning and selecting EHRs
- Fall: Implementation and training
- First week of October: Nine departments went live
- End of October: Remaining two went live
All departments have now had their EHRs in place for one full year.
Training Insights from Sinnova
Sinnova brought tools typically used for hospitals. We asked them to simplify for local health departments. Key tools included:
- Team charter
- Department workflows
- Vendor evaluation tool
- IT and staff readiness assessments
- Template planning
- Communication plans and expectations
Department workflows were especially important. Understanding current workflows and how they translate into an EHR was a major challenge.
EHR Variability and Choosing a System
We learned:
- Public health and private practice EHRs differ significantly
- Clinical and administrative teams often prefer different parts of a system
- Training and customer service matter a great deal
- Costs varied dramatically, from under $10,000 to over $100,000 for the same department
In the end, our 11 health departments selected three different systems. Patagonia Health was one of them.
Implementation
Departments worked on:
- Setting up data elements and workflows
- Training staff
- Testing the system
- Adjusting templates
- Connecting with the state immunization registry, WebIZ
Connecting to WebIZ was slower than anticipated, with delays both at the state level and with vendors.
Benefits of the Group Approach
Implementing as a group led to:
- A shared facilitator role
- Self-imposed deadlines
- Peer accountability
- Shared templates and best practices
- Stronger relationships
- Financial leverage for group purchasing, training and enhancements
Q and A (Selected)
Question: Is your practice management system set up to bill for preventive services under ACA?
Answer: Yes, we can handle that. All coding is built into the system.
Question: Are the coding manuals available to the public?
Answer: Yes, they are available through the CDC website and through this grant project.
Question: Staff turnover is a major challenge. How was it addressed?
Answer: We experienced three new directors and five staff changes in 18 months. Peer support, group training and assistance from Patagonia were crucial.
Outcomes: The Good and the Bad
The Good
- Financial benefits observed
- Some staff satisfaction improvements over time
- Increased productivity
- Reduced billing burden in several departments
- Strong data-sharing relationships
The Bad
- Double data entry persisted for nearly a year
- More EHRs in the state meant more variation
- Staff turnover disrupted progress
- Some departments who operated outside the group struggled
Surveys and Data
We collected:
- Financial data across three years
- Staff satisfaction surveys at three months and one year
- Internal workflow change observations
Early results:
- A slight increase in revenue despite disruptions
- A 14 percent increase in encounters
- Mixed staff reactions early on, expected to improve over time
Top 10 Tips for Implementing EHRs
- Only implement a system if you truly need one
- Address cultural and process issues first
- Be realistic about the work involved
- Implement as a group when possible
- Build a strong internal team
- Measure everything you can
- Learn all features and benefits, not just the shiny parts
- Recognize pitfalls and negotiate contracts carefully
- Do not purchase without seeing the system live
- Plan thoroughly, including assessments and workflows
Final Notes and Closing
We are working on revamping all tools used in this project, including the vendor demo script, to make them health department specific. These will be part of our final CDC report, expected in early 2017, and will be shared widely.
Monique: We will email the slides and recording to all attendees once the recording is uploaded, either this afternoon or Monday. We appreciate the work Aaron is doing in Kansas, and we know it can benefit other states as well. Thank you Aaron for presenting today and thank you all for attending. Once I receive the coding manual from Aaron, I will include that in the follow-up email.
Aaron: Thank you very much.
