Aggregators Implementing the CHCF Small … · Web viewThe template is a MS Word document that can...

Table of Contents

Overview of the Toolset..........................................................................................................4

What Is the Role of the Small Practice Aggregator?.................................................................5

The Small Practice eDesign Model...........................................................................................5

The Business Case for Physicians – Lessons from SPeDesign Adoption.....................................6

The Seven Steps for Successful SPeDesign Adoption................................................................7

Appendix: The Toolset............................................................................................................9Step 1: Build Awareness of Electronic Health Records (EHRs), the Small Practice eDesign (SPeDesign) Model, and the Role of Aggregators.........................................................................................................9

Tool 1.0: Overview of Step 1 and Related Tools...........................................................................................................9Tool 1.1: Background on EHR Adoption for Small Practices..................................................................................9Tool 1.2: What is the SPeDesign Model?....................................................................................................................... 10Current Small Practice EHR Options............................................................................................................................... 11Tool 1.3: The Role of the Aggregator............................................................................................................................. 14

Step 2: Evaluate the Suitability of SPeDesign.............................................................................................................16Tool 2.0: Overview of Step 2 and Related Tools.........................................................................................................16Tool 2.1: What Makes SPeDesign Successful?............................................................................................................. 17Tool 2.2.1: Detail of Aggregator Tasks and Responsibilities................................................................................19Tool 2.3: Online Survey - Evaluating Member Interest..........................................................................................19Tool 2.4: Focus Group Discussion Guide - Evaluating Member Interest.........................................................19Tool 2.5: The Role of Trust in SPeDesign Implementation...................................................................................20Tool 2.5.1: Aggregator Self-Assessment........................................................................................................................ 21Tool 2.6: Member Trust of Aggregator – Survey Template..................................................................................21Tool 2.7: Aggregator Roles and Responsibilities.......................................................................................................22Tool 2.8: Investment Requirements................................................................................................................................ 23Tool 2.8.1: athenahealth Master Services Agreement............................................................................................23Tool 2.8.2: eCW Master Services Agreement............................................................................................................... 23Tool 2.8.3: Practice Cost Estimator................................................................................................................................. 24

Step 3: Prepare the Aggregator.........................................................................................................................................25Tool 3.0: Overview of Step 3 and Related Tools.........................................................................................................25Tool 3.1: Communicating the Vision.............................................................................................................................. 25Tool 3.2: Project Plan with Timeline.............................................................................................................................. 25Tool 3.2.1: Overview of Project and Timelines........................................................................................................... 25Tool 3.2.2: SPeDesign Implementation Timeline......................................................................................................25Tool 3.2.3: SPeDesign Aggregator Project Timeline................................................................................................25Tool 3.3: Preparing the Aggregator to Engage Practices.....................................................................................26Tool 3.3.1: Small Practice eDesign Curriculum Overview.....................................................................................26Tool 3.3.2: Small Practice eDesign Aggregator Coaching Playbook................................................................27Tool 3.4: Aggregator Technical Handbook................................................................................................................. 27Tool 3.4.1: SPeDesign Model Software Architecture...............................................................................................27Tool 3.4.2: Solo Practice Hardware Configuration..................................................................................................27Tool 3.4.3: Network and Connectivity Requirements..............................................................................................27Tool 3.4.3.1: athenahealth Technical Requirements...............................................................................................27

Tool 3.4.3.2: eClinicalWorks Technical Requirements...........................................................................................27Tool 3.4.3.2a (1-2 providers) Tool 3.4.3.2b (3-9 providers)Tool 3.4.4: System Integration.............27Tool 3.4.4: System Integration.......................................................................................................................................... 28Tool 3.4.4.1: eClinicalWorks Charge Specifications.................................................................................................28Tool 3.4.5: Laboratory Orders and Results.................................................................................................................. 28Tool 3.4.6: Aggregator Technical Support Model..................................................................................................... 28Tool 3.4.7: Aggregator Technical Support Roles and Responsibilities............................................................28Tool 3.4.8: SPeDesign Technology Lessons Learned and Implementation Hints........................................28

Step 4: Assess, Enroll, and Prepare Practices.............................................................................................................29Tool 4.0: Overview of Step 4 and Related Tools.........................................................................................................29Tool 4.1: Sample Small Practice Outreach Materials..............................................................................................29Tool 4.2: Physician and Practice SPeDesign Readiness Assessment.................................................................29Tool 4.2.1: Practice Staff Computer Skills Checklist................................................................................................29Tool 4.2.2: Is Your Practice Ready for Change?.........................................................................................................29Tool 4.2.3: Why Does Our Phone Ring?......................................................................................................................... 30Tool 4.3: Practice Agreement Process and Forms....................................................................................................30Tool 4.4: Vendor Contract Information......................................................................................................................... 31Tool 4.4.1: EHR Contract Negotiation Tips................................................................................................................. 31Tool 4.4.2: HIPAA Business Associate Agreement.....................................................................................................31Tool 4.5: SPeDesign Rollout............................................................................................................................................... 31Tool 4.5.1: Aggregator Action Checklist....................................................................................................................... 31A list for the aggregator to use to keep track of the completion of SPeDesign tasks, across Steps 4, 5, and 6 for up to 15 practice sites........................................................................................................................................ 31Tool 4.5.2: Project Rollout Kickoff Questionnaire..................................................................................................... 31Tool 4.5.3: SPeDesign Improvement Projects............................................................................................................. 32Tool 4.6: Potential Community Healthcare Partner Outreach...........................................................................32Tool 4.7: Staff Activity Surveys.......................................................................................................................................... 32Tool 4.7.1: Physician and Nurse Activity Survey.......................................................................................................32Tool 4.8: Providing CME Units.......................................................................................................................................... 32Tool 4.8.1: CAFP CME Workbook..................................................................................................................................... 33Tool 4.8.2: SPeDesign Learning Community Evaluation Form...........................................................................33Tool 4.8.3: SPeDesign Learning Community Sign-in Sheet...................................................................................33

Step 5: Implement Phase I - Revenue Management................................................................................................34Tool 5.0: Overview of Step 5 and Related Tools.........................................................................................................34Tool 5.1: What is Revenue Management?.................................................................................................................... 34Tool 5.1.1: Overview of athenaCollector....................................................................................................................... 35Tool 5.2: Pilot Practices’ Experience with Revenue Management.....................................................................35Tool 5.3: Revenue Management Implementation Project Plan..........................................................................36Tool 5.4: Setting Practice Expectations........................................................................................................................ 36Tool 5.4.1: Getting to Green-RCMS Best Practices Checklist.................................................................................36Tool 5.4.1.1: Getting to Green – Best Practices Draft Policies..............................................................................36Tool 5.4.1.2: RCMS Goals..................................................................................................................................................... 37Tool 5.4.2: athena Sample Practice Performance Review....................................................................................37Tool 5.4.3: athena Sample Physician Performance Review..................................................................................37Tool 5.4.4: Abstraction Time Planning Calculator...................................................................................................37Tool 5.5: Physician Satisfaction Tool............................................................................................................................. 37Tool 5.6: Practice Staff Satisfaction Tool..................................................................................................................... 37Tool 5.7: Patient Satisfaction Tool.................................................................................................................................. 38Tool 5.8: Tools for the Learning Community Curriculum.....................................................................................38

Tool 5.8.1: Anatomy of a Huddle...................................................................................................................................... 38Tool 5.8.2: Escaping the Tyranny of the Urgent by Delivering Planned Care...............................................38Tool 5.8.3: Creating a High-Performance Clinical Team.......................................................................................38Tool 5.8.4: Great Tips for Patient Scheduling............................................................................................................. 38

Step 6: Implement Phase II - EHR and Workflow Changes...................................................................................39Tool 6.0: Overview of Step 6 and Related Tools.........................................................................................................39Tool 6.1: Overview of eClinicalWorks............................................................................................................................ 39Tool 6.2: eClinicalWorks and ELINCS Implementation..........................................................................................39Tool 6.2.1: ELINCS HL7 Release 1 (HL7-R1) Interface Implementation Guide............................................39Tool 6.2.1.1: ELINCS HL7-R1 Interface Project Plan...............................................................................................39Tool 6.2.1.2: EHR Implementation Test Script........................................................................................................... 39Tool 6.2.1.3: ELINCS HL7-R1 Lab Result Interface Test Plan..............................................................................40Tool 6.2.1.4: ELINCS HL7-R1 LOINC Codes................................................................................................................ 40Tool 6.2.1.5: ELINCS HL7-R1 Specification Review..................................................................................................40Tool 6.3: eClinicalWorks Implementation Tips.........................................................................................................40Tool 6.3.1: Prepping for eCW Go-Live............................................................................................................................ 40Tool 6.3.2: Results Management Tip Sheet.................................................................................................................. 40Tool 6.3.3: Getting Ready for the Patient Portal....................................................................................................... 41

Overview of the ToolsetThis toolset is a guide for organizations whose administrators would like to help small physician practices implement electronic health records (EHR) and practice management systems, by adopting the California HealthCare Foundation’s Small Practice eDesign (SPeDesign) model. The guide aims to clarify the SPeDesign model and support aggregators and practices who choose to adopt the model.

The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, the goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford.

Strong primary care practices are a cornerstone to receiving effective health care in California, yet primary care practices are under tremendous pressure. Implementing electronic health records allows practices to improve the health of their patients, create financially sustainable practices, and provide greater practitioner satisfaction and a sustainable work life balance. CHCF invested in creating a model to help practices implement electronic medical records and practice management software, based on the belief that this innovation is fundamental to revitalizing primary care in California.

CHCF acknowledges that there are many ways to encourage adoption and meaningful use of electronic medical records. We recognize that not only is SPeDesign is just one model; it is also a work in progress. The guide presents the SPeDesign model, including the tools and processes that the development team created, and a compilation of lessons learned from SPeDesign’s pilot implementation in Tulare County, California. The pilot included two waves of participating practices, along with an early evaluation, but SPeDesign has not been fully tested. This is not a training manual on the selected software; it is a guide for aggregators to help physicians of small practices adopt electronic health record and practice management software, and help them transform their practice in the process.

What Is the Role of the Small Practice Aggregator?This model was designed well before the federal approval of ARRA and HITECH funding and the plans for regional extension centers. The original SPeDesign plan called for aggregators to be local trusted physician advisors and to provide technical support for small practices to implement HIT solutions and improve their practice processes. Aggregators could be independent practice associations, medical societies or foundations, or other community-based organizations that have the trust of local doctors and can organize these physician communities to make a commitment to implementing HIT. Multiple organizations could also work together in an aggregator partnership. Since some anticipated aggregators might not currently see themselves as technical and quality improvement support providers, this guide is designed to provide information and tools necessary for an aggregator’s success in this role. Given the federal ARRA and HITECH funding, it is likely that regional extension centers (RECs) will be the community aggregators and will provide the technical support.

A local practice aggregator’s main responsibilities will be to recruit and engage practices to adopt revenue management and EHR systems, and then to provide project management, local coaching, and hands-on IT support to participating practice teams. The critical task throughout the project is to teach practices to use HIT to create data-driven improvement processes to improve patient population health.

The Small Practice eDesign ModelSmall Practice eDesign is a community-based standardized solution to support small physician practices to convert to electronic revenue management (athenahealth) and electronic health record (eClinicalWorks, or eCW) systems and transform their practices. The solution relies on a local physician-trusted aggregator organization to provide participating practices with ongoing support in implementing athenahealth and eCW. During the pilot wave of SPeDesign, the advisory team developed a pre-configured sequence of activities and tools to assist with technology adoption and workflow changes in participating practices. The software and hardware (Dell computers) come bundled together in an industry-standard package that is pre-configured for a lower purchase cost. The aggregator has the crucial role of organizing a majority of local practices to adopt this same solution; this ensures economies of scale in cost, consistency across the provider community, and standardized data flows from ancillary services such as labs. The theory is that the success so far of SPeDesign implementation will encourage future practices to be more likely to commit to the model. SPeDesign’s success factors include:

With one model (SPeDesign) implemented communitywide, all participating practices and the aggregator organization have equal, vested long-term interests in ensuring the success of the model.

SPeDesign is a two-step process of revenue management sequenced by health records to ensure that physicians manage the change process effectively, adopt new practice workflows, and generate funds and practice stability through improved billing and collection processes.

SPeDesign focuses on patient health and provider satisfaction. The SPeDesign model appears to improve clinical outcomes, financial stability, physician

and staff satisfaction, and patient health. It is being implemented in more than ten practices in Tulare, California, with the Foundation for Medical Care of Tulare and Kings Counties (TKFMC) as the local aggregator.

Model Details: The SPeDesign model uses Dell hardware bundled with athenahealth’s revenue management software and eCW’s records and practice management software. Packaging the hardware and software in a bundle allowed for pre-negotiated pricing to simplify implementation

and lower costs. The package uses centralized hub architecture with Web-based software (each practice has its own database), which allows the aggregator to provide support, troubleshoot data interfaces, and monitor participating practices using a central automated dashboard of predetermined indicators; this aggregator support helps practices maximize the use of automated feedback reporting to support improvement.

The software was selected in 2008 with criteria for the practice and revenue management functionality, revenue cycle outsourcing, EMR functionality, clinical documentation, and consumer portal tasks.

At the time of selection athenaHealth was assessed as having the most robust revenue management functions and eClinicalWorks the strongest electronic practice and records management system, suitable for the target market. The evaluation included vendor’s own responses, references from current users, and team assessment.

The critical factor in selecting the solution is to ensure the community of primary care practices supported by the aggregator all commit to the same solution for economies of scale of initial and ongoing support. The CEO of the Tulare aggregator Steve Beargeon commented “it’s all about eliminating the variables to ensure effective support; it’s simply not possible to support practices with different applications…nobody debates the software in later meetings, they all talk about how their practices now run more efficiently.”

The Business Case for Physicians – Lessons from SPeDesign AdoptionTraditional business cases for innovation adoption simply outline the costs of implementation versus the financial benefits. For electronic medical records and practice management adoption the business case is more about ensuring the ongoing viability of a practice. The complexity and volume of non-clinical tasks including revenue management has created practices with unsustainable cost structures and physician time burdens. Simply, without electronic tools primary care practices may be unsustainable. Electronic management tools are now part of the cost of managing a practice.

In early discussions with physician owners with SPeDesign, the key topics were the cost and selection of the software solution. In later conversations, the physicians noted the new way of running a practice that allowed them to

Increase the number of new patients Better manage chronic disease and improve overall population health Bill appropriately for all procedures for greater revenue Spend more time on clinical care and less on administration Recommit to the satisfaction of being a primary care provider with a work life balance

In early meetings with physicians, aggregators will need to answer specific questions on why the specific software tools were chosen and the costs of the applications, ongoing support, interfaces, connectivity and maintenance; and the anticipated revenue increases. (Tool 2.8.4 provides details of the cost of the SPeDesign software.) However aggregators will also need to communicate the broader benefits of a long-term sustainable practice.

The Seven Steps for Successful SPeDesign AdoptionDifferent aggregators will need different tools to assess and implement SPeDesign. However, the basic adoption process is likely to be similar for all aggregator organizations, and will consist of six steps. This guide is organized into six chapters, one for each step, with a set of tools or guidelines,

along with FAQs, to help the aggregator assess and then implement SPeDesign. . The seventh step has yet to be fully developed as the federal definition of “meaningful use” has not been finalized.

Tool Icon LegendThroughout the Toolset, icons are used to highlights tools and other key pieces of information. These icons are intended to help you find information more quickly when you are using this document as a reference. Following is an overview of what each icon means.

The Tools icon indicates a link to other information such as a manual, checklist, presentation, slide deck, spreadsheet, or other documents. The tools are downloadable, and are created using MS Office 2007.

The Key Learning icon indicates a critical insight developed by the pilot team.

The Vendor Information icon indicates that there is a downloadable file on a vendor’s specific products. The vendor provided this information.

The Tech Toolkit icon indicates there is a tool for the use of the IT professionals who install and support the hardware and software. These tools were developed by the pilot’s technical team.

The Tulare Experience icon highlights insights from the implementation team on the ground in Tulare County. This team included technical, training, and coaching support and the practice physicians and managers.

The Caution icon highlights useful information to be aware of during the implementation.

The www link icon provides links to information on the world wide web.

SMALL PRACTICE EDESIGN PRACTICE AGGREGATOR GUIDEINTRODUCTION –

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Appendix: The Toolset

Step 1: Build Awareness of Electronic Health Records (EHRs), the Small Practice eDesign (SPeDesign) Model, and the Role of Aggregators

Tool 1.0: Overview of Step 1 and Related ToolsThis step and its tools are designed to help aggregators understand their role in EHR adoption, as well as to provide aggregators with a solid understanding of the Small Practice eDesign (SPeDesign) model. The tools in this step provide a compilation of information on small practice EHR adoption, and aim to clarify the CHCF model of SPeDesign for potential aggregators.

The SPeDesign model was designed and implemented in Tulare County prior to federal ARRA and HITECH funding and the regional extension center (REC) applications or appointments. The original intent was for organizations such as independent practice associations, medical foundations or societies, or health plans to be the aggregators with the role of helping their members adopt electronic health records and revitalize their small primary care practices; however, the first wave of aggregators may be RECs who have a mandate for this role.

Tool 1.1: Background on EHR Adoption for Small PracticesThis tool suggests a number of documents that provide supporting data and information for the adoption of electronic health records for small practices.

The Value Of Electronic Health Records In Solo Or Small Group PracticesRobert H. Miller et al, in Health Affairs 2005 24, no. 5 (2005): 1127-1137doi: 10.1377/hlthaff.24.5.1127Downloadable at HealthAffairs.doc

Several other studies either focused on or cross-referenced Appreciative Inquiry (AI) approaches1 as a strategy for engaging primary care practices in improvement efforts.

Two Canadian researchers who studied 20 published cases of organizational change where the AI methodology was used prepared an interesting article2. They found that AI held substantial merit when transformative change was required, although they found it of less value in typical organizational change efforts. In essence, it appears to offer substantial value as a motivating force when deep change is required, if thoughtfully incorporated with proper planning and flexibility.

1 Most useful was Caroline Carter, et.al., “An Appreciative Inquiry Approach to Practice Improvement and Transformative Change in Health Care Settings” Quarterly Manage Health Care, 2007, Vol. 16, No. 3, pp. 194-204.2 Gervase R. Bushe and Aniq F. Kassam, “When is Appreciative Inquiry Transformational? A Meta-Case Analysis”, The Journal of Applied Behavioral Science, 2005, Vol. 41, No. 2, pp. 161-181.

SMALL PRACTICE EDESIGN PRACTICE AGGREGATOR GUIDESTEP 1 –

Case Western Reserve3, published research on factors associated with practices “capacity for change”. While the study was for the purpose of improving research on the topic of practice change, several observations are useful in implementing SPeDesign.

The Tulare pilot evaluator reporting on the pilot practices’ desired outcomes: “Improved patient care, particularly preventive care, was the primary desired outcome mentioned by providers. Almost equal to desires for improved patient care were hopes to improve efficiency – to reduce patient wait times, reduce paperwork and duplication of effort, streamline pharmacy and referral processes, minimize pulling and re-filing of charts, and improve office staff experience and/or salaries.”4

Tool 1.2: What is the SPeDesign Model?SPeDesign is a community-based standardized model for supporting small physician practices to convert to electronic revenue management and electronic health record systems. The model relies on a local physician-trusted organization, known as an aggregator (see Tool 1.3 – The Role of the Aggregator), to provide practices with onsite implementation support using a pre-configured sequence of activities and tools to assist with technology adoption and workflow changes. The software and hardware package is industry standard and pre-configured for a lower purchase cost. The aggregator organizes a majority of the local practices to adopt the same solution to ensure economies of scale in cost, consistency across the provider community, and standardized data flows from ancillary services such as labs.

Key Features of the SPeDesign Model: This is a working model that appears to improve clinical outcomes, financial stability,

physician and staff satisfaction, and patient health. It has been implemented in more than ten practices in Tulare County, California, with the Foundation for Medical Care of Tulare and Kings County (TKFMC) as the local aggregator.

The SPeDesign approach is not just about technology, but about re-energizing primary care, making practices more robust, and improving patient outcomes by changing how they do their work.

SPeDesign focuses on improving the practice experience for both patients (better health) and physicians and their staff (higher satisfaction).

Aggregators, trusted local organizations with an interest in and commitment to improving the health of their communities, support practices in their improvement efforts and organize the whole community around a single technology solution. A single solution gives all parties equal vested long-term interest in ensuring success in a single community system.

The software component of SPeDesign is installed in two phases. In Phase I, practices install and implement athenahealth’s revenue management software, to improve practice billing processes. In Phase II, they install and implement eCW’s EHR and practice management software, to improve patient care.

3 David Litaker, et al, “Making Sense of Primary Care Practices’ Capacity for Change”, Translational Research, September 2008, 245-253.4 SPeDesign Evaluators Quarterly Report November 2009


The SPeDesign development team has secured a hardware agreement with Dell. A bundled product and pre-negotiated pricing simplify implementation and lower costs to the practices.

With the SPeDesign model, aggregators consistently coach practices on making data-driven improvements to both workflow and patient outcomes.

The SPeDesign model was developed and evaluated by independent advisors working with the California HealthCare Foundation (CHCF), a trusted source of health care information.

Current Small Practice EHR OptionsOverall, physicians have limited options for EHR adoption. Given the perceived difficulty of selecting and implementing a system, some may simply choose to do nothing. Others may choose to purchase their own systems, either off-the-shelf or through a vendor of their selection. Many, though, may adopt community-based systems that are introduced to them through an external organization, such as a local hospital, medical foundation, or IPA.

Spectrum of Options for Small Practices 1

The most competitive option to SPeDesign is likely to be the local hospital’s solution, which may in some cases be offered free to providers. This serves the hospital’s interests because it connects them to local practices and generates referrals; however, these technology solutions are likely to be more sophisticated than a small practice needs and may not include technical support. Technology is just the start; the difficult part for physicians is having the training and support to use the new technology effectively and modernizing how they practice. Physicians and managers should first determine if they are willing to take on the hard work to change, and then determine if a solution is suitable for their practices by evaluating the total cost of different solutions, including hardware, software, training, support, and ongoing fees. The SPeDesign solution has economies of scale because aggregators can centrally manage local data interfaces, troubleshoot, and train and support practice staff. While HIT adoption is critical to the SPeDesign model, the ultimate goal of SPeDesign is to move small practices toward continual process and quality improvement.


Community-Based/SupportedIndependent/Unsupported

HIT Challenges and the SPeDesign Solution

The SPeDesign model may address many of the issues that can cause practices to fail or falter in EHR implementation.

The Problem The SPeDesign SolutionChoosing an EHR is complicated and time-consuming, and small practices are often taken advantage of in the contracting process.

External review identified the “best in show” technologies for small practices in California. Contractual agreements with athenahealth and eClinicalWorks are standardized and terms have been tested.

Physicians need to keep up with emerging federal and state requirements in order to qualify for HIT incentives (aka meaningful use).

SPeDesign is specifically designed to help practices meet meaningful use criteria.

EHR adoption is difficult, and in order for it to be successful, practices usually need to change their workflows.

The model includes a process and tools aggregators can use as guides to help support practices in their practice redesign efforts.

Hardware setup and maintenance are challenging, and practices are vulnerable when things don’t work.

Aggregators will provide local support and troubleshooting, and the negotiated hardware agreements include tested warranties.

Software is also a challenge. Aggregators such as health plan administrators have software that can track what’s happening at practices, but the software they use doesn’t usually interface with EHR and revenue management software.

Aggregators can use the SPeDesign model software to have a view into what’s going on with individual practices.


Frequently Asked Questions about the SPeDesign ModelQuestion AnswerSome of our physicians have existing EHR or billing and revenue management systems – can we have several software solutions within the group?

Our experience so far suggests that it is important for the group to have the same solution. It ensures that the aggregator can provide support easily and cost effectively across the whole group, and it allows for group learning and of economies of scale for purchasing. We required physicians who had existing systems to replace them with the standard SPeDesign hardware and software package.

Why not combine the installation of revenue management with the EHR?

We found a two-step process offered significant benefits, including the ability for a practice to generate revenue to stabilize the practice, learn the approaches to data-driven workflow improvements, and experience success with technology.

Do we need to use the same software you used?

The pilot practices experienced success with athenahealth and eClinicalWorks. At the time we assessed the market, athenahealth had the strongest solution for revenue management and the ability to teach practices workflow changes. Our experience is only with these products so we cannot advise you on using other solutions.


Tool 1.3: The Role of the Aggregator

Aggregator ProfileA small practice aggregator (aggregator) will be a local trusted organization that can galvanize and organize the community of small practice physicians, provide technical support for small practice HIT implementation, health technology solutions and revitalize small physician practices. Aggregators might be independent practice associations, medical societies, foundations, or other community-based organizations that have the trust of local doctors and can organize these physician communities to commit to implementing health technology and to changing how they work. Some aggregators may be a combination of two entities working together, bringing their respective skills and relationships to bear.

Aggregator RoleAggregators are the key to the successful implementation of the Small Practice eDesign model. The aggregator will have the following responsibilities:

Attract and engage small physician practices interested in using practice technology and workflow changes to improve patient health.

Provide local coordination and technical expertise to support (onsite, telephonic, etc.) implementation.

Provide centralized support and troubleshooting for HIT systems, namely interface development and management (for example, between the revenue management and EHR systems, as well as data interfaces for the flow of laboratory, hospital discharge, and radiology information).

Host and lead training sessions on software tools and practice workflow changes, and follow up with practices to monitor success.

Assist physicians in managing the practice change process, for all practice staff and for the practice itself (with a focus on team development and communication).

Share the business case with practices - collect and organize information, data, and stories that show the tangible value of the project to physician practices.

Organize and use data to help practices improve performance (that is, support data-driven performance improvement).

Work with other local providers (labs, local pharmacies, imaging centers, etc.) to support the electronic exchange of information.

Ensure community support by involving the broader community, including engaging the business community, and providing recognition to participating physicians.

Steve Beargeon, CEO of TKFMC, aggregator for the pilot implementation: “We did this (implemented SPeDesign in our community) to improve the community; we need to improve health in our community. Our goal is to walk out and have a better health care. And we have an IPA so we gain other benefits with increased reimbursement; every transaction processed electronically is more efficient for the practices and for us so we have saved money. Importantly we are also seeing higher quality measures, such as greater use of mammograms, improved chronic care measures.”


“Why did practices trust us? We have PCPs on our board with the trust of the local practices; we have a reputation for strong technical staff who had previously worked in local offices and had the IT skills.”

“…my advice: limit the products; limit the moving parts; don’t try to bring a broad range of technology or it won’t get done. Make sure you have the right IT staff who are excited about the project. Be a benevolent dictator and say this is the way it will be done.”


Step 2: Evaluate the Suitability of SPeDesign

Tool 2.0: Overview of Step 2 and Related ToolsAggregators need to understand the skills required for successful implementation of the Small Practice eDesign model; the tools in Step 2 help clarify the aggregator’s role in SPeDesign.

Tool 2.1 identifies the factors that contribute to the success of SPeDesign. Tool 2.2 gives an overview of the aggregator’s role in implementing SPeDesign, while Tool 2.2.1 outlines specific aggregator responsibilities. Tools 2.3 and 2.4 offer ways for aggregators to determine if any of their members are interested in participating in implementing electronic health records using the SPeDesign model; Tool 2.3 gives a survey template aggregators can use, and Tool 2.4 is a discussion guide aggregators can use to lead focus group discussions on member interest. Tool 2.5 discusses the role of trust in an aggregator’s ability to support practices through the implementation of SPeDesign; Tool 2.5.1 is a self-assessment aggregators can use to determine how much their member organizations trust them to provide the support; Tool 2.6 is a survey aggregators can distribute to members directly, testing how well practices trust the aggregator. Tool 2.7 outlines the support roles that will be necessary to support practices in implementation; except for the technical support provided by Dell, aggregators should be prepared to have staff perform these roles. Tool 2.8, lays out the investments practices should be prepared to make if they are going to implement the SPeDesign model.


Tool 2.1: What Makes SPeDesign Successful?Tool 2.1 summarizes the key elements of successful SPeDesign implementation. It offers a guide to the SPeDesign model’s key elements, and indicates why each element is critical to success. Full commitment to SPeDesign requires use of specific hardware and software, as well as rigorous observation of timelines and checklist tasks; the table below also lists common questions that physician practices asked regarding the model and implementation.

We recognize that there are many ways to encourage adoption and meaningful use of electronic health records, and that SPeDesign is only one model. Although the pilot included two waves of participating practices, along with an early implementation evaluation, SPeDesign is not fully tested.

SPeDesign Model Element

Why is it essential for success? Notes & Frequently Asked Questions

All practices commit to using the same software and hardware.

Providing technical support on the same software and hardware offers economies of scale for the aggregator. Using the same package lowers the purchase price for all participants, allowing for a streamlined purchase process, and simplified training across a community.

Using a single solution across a community also ensures standardized data flows from ancillary services such as labs.

Several potential aggregators asked if all practices needed to adopt the same software. The SPeDesign pilot experience suggests that using the same software is critical for streamlined support and training.

If you wish, you may attempt to use this guide in conjunction with other software, but the SPeDesign pilot experience used athenahealth and eClinicalWorks, implemented in sequence.

The SPeDesign model uses athenahealth and eCW and a standard hardware kit from Dell.

The software was selected after thorough review; it provides a community dashboard and effective processes. Hardware was similarly carefully selected.

At the time we assessed the market, athenahealth had the strongest solution for revenue management along with the ability to teach practices workflow changes.

Potential aggregators asked if this software was the sole solution. The pilot program used only these products so we cannot provide advice on using other solutions.

The software is Web-based (each practice has its own database) yet allows for centralized management and data security.

Web-based software allows the aggregator to troubleshoot data interfaces and use a central automated dashboard of indicators (clinical, revenue, others) to support the practices.


Software is implemented in two phases alongside an approach that teaches the use of data to drive improvements.

Implementing the revenue management application provides financial stability for the practices through improved billing and collection processes, and is the easier way to learn data-driven improvements.

Some practices asked if they could implement both applications simultaneously. Although this is possible, the SPeDesign model advocates implementation in two phases in sequence. Staggered installations and training allow a practice to maintain financial stability by maintaining at least partial practice capacity. Staggering installations gives staff sufficient opportunity to learn data-driven improvements and new workflow approaches, before moving on to implement patient electronic health records.

SPeDesign’s aggregator provides hands-on technical support of a hardware and software package common across the community. Use of the same system across community increases aggregators to offer better service through familiarity with the systems.

Practices need to know there is local technical support from a committed source that is an integral part of their community.

Individual practices and the aggregator have equal vested long-term interests in ensuring success in a single community system.

The pilot’s evaluator: “...physicians were highly complementary of the local technical support (practices) “we’ve gotten ten times the amount of support we have gotten if we did it on our own”5

Practices’ previous experience was that vendors “dropped software at their door” with little support and no local contact. The SPeDesign aggregator provides support but also confidence in the model.

SPeDesign uses technology adoption and process workflow changes to improve patient health and provider satisfaction.

Practices are unlikely to commit to revenue management or EHRs solely for financial benefits. They are more interested in patient health and provider (and staff) satisfaction.

5 Evaluator’s Report Interim Summary Report SPeDesign Wave I Physician Interviews January 2010


Tool 2.2: SPeDesign Aggregator Tasks and ResponsibilitiesThe SPeDesign practice aggregator (see Tool 1.3 – The Role of the Aggregator and Tool 2.2.1 – Detail of Aggregator Tasks and Responsibilities) is a local trusted organization that can galvanize and organize small practices (typically defined as a practice with two or three providers, but no more than ten) to implement health technology solutions. Aggregator activities will consist of soliciting small practice participation, providing technical support to the practices, running local learning communities in which practices can share learning and experiences, and other responsibilities as detailed below. An aggregator organization could be an independent practice association, a medical society or foundation, or other community-based organization. Individual organizations may feel prepared to take on some aggregator duties but not all; therefore, an aggregator could also be a combination of two organizations working together.

The most important characteristic necessary for success as a local aggregator is having the trust of the local physician community. The implementation of EHRs in either a specific practice or a community can be a very challenging process, and aggregators must have the community’s trust in order to guide practices through the difficult stages of implementation.

Tool 2.2.1: Detail of Aggregator Tasks and Responsibilities

A six-page guide with details on what will be expected of an organization that is considering becoming a SPeDesign model practice aggregator.

Tool 2.3: Online Survey - Evaluating Member Interest

A survey template that aggregators can use to gauge the interest of member practices in implementing the SPeDesign model. The template is a MS Word document that can be edited and used to create an online survey.

Tool 2.4: Focus Group Discussion Guide - Evaluating Member Interest

A discussion guide that aggregators can use to gauge the interest of member practices in implementing the SPeDesign model. The guide is a MS Word document that can be edited.


Tool 2.5: The Role of Trust in SPeDesign Implementation

Based on the Trusted Advisor Model6

Trust relationships are vital for aggregators to recruit practices. The level of trust in the practice-aggregator relationship is a significant determinant of success. Even getting physicians and practices to consider adopting the Small Practice eDesign model requires trust. For practices to commit to making an investment, changing their workflows, and integrating across a community, significant trust must be present between practices and the aggregator, including trust that the aggregator has the competency or expertise to fully support the practices.

This information and the linked tool – Tool 2.5.1 – Aggregator Self-Assessment - are designed to help aggregators assess the degree to which they have the trust of their communities, and determine the drivers of that trust. If aggregator organizations find they are not well trusted, or if they are unable to determine an accurate level of trust, this tool can also help determine steps to build trust in the community; the tool can also help aggregators determine what, if any, local partnerships might be worth pursuing to ensure success with the model.

Tool 2.5 first lays out the core trust models developed by David Maister and his team. They are taken from The Trusted Advisor. The self-assessment tool is a series of questions on the components of trust, for the aggregator to consider.

There are three components to trust.1. The Trust Principles: four principles, or values, which serve as guides to decision-making

and conduct to increase trust

2. The Trust Creation Process: creating trust though interactions

3. The Trust Equation: an analytical model of the components of trustworthiness

The Trust PrinciplesBeing or becoming trustworthy cannot be reduced to pure behaviors. Actions are driven by our beliefs, and our beliefs are driven by values or principles. Trustworthy behavior is too complex to fake without being backed by firm beliefs and values.

According to Maister, the primary four values, or principles, of trust are credibility, reliability, interactions, and self-orientation. Credibility has to do with spoken words and demonstrated knowledge and skills. In contrast, reliability has to do with actions. Interactions refer to the willingness to share information or tangible assets. Self-orientation refers to the self-interest of the person or organization being trusted, in particular, whether the person or organization’s focus is primarily on himself or herself; for purposes of SPeDesign, self-orientation refers to whether an aggregator’s focus is on the aggregator or on the participating practices.

The Trust Creation ProcessThe Trust Creation Process is a five-step model involving engaging practices on the substantive issues, listening to what is important to practices, framing without blame, envisioning an alternative reality and co-committing to actions and next steps.The way to become trusted is to act consistently from principles, including:

6 David H. Maister et al. The Trusted Advisor, Free Press September 2001


Focusing on the “other.” In the case of SPeDesign, the aggregator’s focus should be on the participating physician practices and their interests

Using a collaborative approach to relationships, featuring a willingness to work together to create both joint goals and joint approaches to implementation.

Viewing the relationship from a medium- to long-term perspective, rather than a shorter term, more transactional focus.

Being transparent in all dealings. Transparency increases an organization’s credibility, and lowers its self-orientation by showing its willingness to disclose all interests.

The Trust EquationThe trust equation is a model for assessing who is trusted and what drives trust, building on the Trust Principles. Trust in selling new ideas and getting commitment to a solution requires good “scores” on all four variables in the equation.

Credibility + Reliability + InteractionsTrust = ______________________________________________

Self Orientation

Increasing the value of the factors in the numerator increases the level of trust; increasing the value of the denominator—that is, self-orientation—decreases the level of trust. Self-orientation is the most important factor in the trust equation: An aggregator organization must have some focus on itself and must be transparent about its own interests in pursuing the Small Practice eDesign model, but it’s equally important that the aggregator ensure its members’ interests are well served.

Tool 2.5.1: Aggregator Self-Assessment

A self-assessment an aggregator can use to test the level of trust local physicians may have with this aggregator. This self-assessment can highlight drivers of trust and ways to improve trust with local practices.

Tool 2.6: Member Trust of Aggregator – Survey Template

A survey template an aggregator can use to determine the level of trust local physicians may have with this aggregator. This survey can highlight drivers of trust and ways to improve trust with local practices. The survey is a MS Word document and can be edited and used with survey software.


Tool 2.7: Aggregator Roles and Responsibilities

Role Responsibilities Source Time CommitmentProgram Manager

Oversee all aspects of project Ensure milestones are met and

project is on schedule and within budget

Lead the implementation team

Aggregator Full time for first four months of the project, including practice installation of Phase I and II

Technical Lead Provide overall project management for implementation

Oversee hardware and software vendor installations

Troubleshoot Launch implementation model

for practices Support redesign in practices Provide training, business

planning and development, and support during pilot site deployment

Aggregator Full time

Technical Support

Perform onsite assessment to determine power, cabling, and ISP needs

Document legacy infrastructure

Purchase necessary hardware components

Oversee hardware installation and ensure network and hardware are working properly

Troubleshoot problems and provide escalation path for all network and hardware issues

Dell

Lab Interface Analyst

Manage lab interfaces and integration with eCW

Aggregator Part-time role, primarily in Phase II implementation of eCW

CEO of Aggregator

Galvanize local physicians to participate

Motivate the practices to stay with the program

Provide support and encouragement for aggregator staff involved with the program

Steve Beargeon, CEO

Aggregator Initially, 10-20% of time in early phases to gain community acceptance


of TKFMC, the pilot aggregator: “Expect to spend 20% of your time in the early months evaluating the model and communicating with your board and the local community…then about 10% of my time is still needed for ongoing support”7

Tool 2.8: Investment RequirementsTool 2.8 looks at the costs and contracting obligations of implementing SPeDesign. In addition to creating subscription agreements with software vendors, participating practices will also need to purchase the Dell hardware, and create agreements with the aggregator to receive support. Practices will also need to factor in staff time and other costs, in order to come up with a total cost for implementation. Tool 2.8.2 gives practices a worksheet to complete, with the assistance of the aggregator, to come up with total costs to implement SPeDesign.

Tool 2.8.1 shows the contracts practices can expect to sign with athenahealth and with eClinicalWorks and highlights capital (one time) costs and ongoing costs.

The SPeDesign agreements are held as follows:The aggregator holds agreements with practices governing receipt of practice incentive funds, and holds Master Services Agreements with vendors; these stipulate the terms of the ongoing relationship between vendor and aggregator, and stipulate the terms for delivering agreed-upon technical architecture and interfaces.

Each practice will hold a quid pro quo agreement with its aggregator organization, and will hold subscription agreements with athena and with eCW.

Tool 2.8.1: athenahealth Master Services Agreement

Tool 2.8.2: eCW Master Services Agreement

Tool 2.8.3: Practice Cost Estimator

An Excel spreadsheet with capital (one time) and ongoing costs of implementing revenue cycle management and electronic health record software

7 Interview October 2009


Step 3: Prepare the Aggregator

Tool 3.0: Overview of Step 3 and Related ToolsStep 3 begins the concrete work of SPeDesign; this is where aggregators work to prepare projects plans,, secure resources including key staff and recruit practices. Tool 3.1 is a PowerPoint presentation that aggregators can use to communicate with internal or physician practice staff, community and business leaders, and others in the area; the goal is to promote the benefits of SPeDesign to individual practices as well as the community as whole. Tool 3.2 offers two timing tools, a full project plan with milestones, in MS Project, and a separate timeline for aggregators. Tool 3.3.1 is the “playbook” that TKFMC, the aggregator for the pilot wave of SPeDesign implementation, has been using to guide practices through the work of implementing SPeDesign. Tool 3.3.2 is an aggregator coaching book, and tool 3.3.3 outlines the training that staff at TKFMC went through.

Tool 3.1: Communicating the Vision

A MS PowerPoint document aggregators can use to help them talk with practice physicians, managers, nursing staff, patients, media, community and business leaders, and aggregator’s own staff, to gain support

Tool 3.2: Project Plan with TimelineProject plans and timeline overviews

Tool 3.2.1: Overview of Project and Timelines

A timeline for the implementation of SPeDesign, in MS Project

Tool 3.2.2: SPeDesign Implementation Timeline

An MS PowerPoint overview of SPeDesign timelines

Tool 3.2.3: SPeDesign Aggregator Project Timeline

A chart of primary tasks for the aggregator, across the estimated twelve months of SPeDesign implementation and coaching


Tool 3.3: Preparing the Aggregator to Engage PracticesA key element of the SPeDesign model is the use of a local aggregator: a trusted entity that has a vested interest in the success of small physician practices in a geographic area. The SPeDesign plan calls for aggregators to be local trusted physician advisors that provide technical support for small practices to implement HIT solutions and improve their practice processes. The aggregator’s main responsibilities are to recruit and engage practices to adopt revenue management and EHR systems, and then to provide project management, local coaching, and hands-on IT support to participating practice teams. The critical task throughout the project is to teach practices to use HIT to create data-driven improvement processes to improve patient population health and reenergize practices.

Many small practices are not managed with tools or processes to ensure successful business outcomes. Given this, the SPeDesign model starts with implementation of revenue cycle management, followed by EHR implementation. This approach leverages HIT tools to first make the practices more financially viable, while providing coaching and automated data feedback on data driven processes and results. This sequence provides the opportunity to enhance communication skills within the office, create a team with clear individual roles and responsibilities, and learn together how to change the practice (all with data to help the practice improve). These skills are developed in preparation for EHR adoption and then further refined as the EHR is implemented.

Practices perceive EHR implementation will slow practice productivity and receipts, at least at initial implementation. The phased SPeD approach provides additional funds (from revenue management efficiencies) at a time when patient schedules are pared back and reallocates staff time from revenue management issues to training on the new system and clinical support to the physician.

The SPeDesign model teaches skills needed to successfully transform a practice. These skills are far beyond IT literacy and HIT adoption, and include management, communication, team building, and a patient focus. These skills, combined with the reallocated time and continuous feedback of data, are the true drivers of continuous improvement in care and the “meaningful use” of EHR systems.

The learning approach used in the SPeDesign pilot in Tulare County is a combination of group learning sessions and individual practice coaching. The Tulare practices highly valued the opportunity to learn together, from one another, and to have a shared, common system in their community. Learning was augmented with preparation prior to training programs and maximized the training time and experience.

An overview of the curriculum presents key themes, by month for the group learning sessions and in practice coaching/support visits. The aggregator curriculum coaching playbook provides greater detail, and references specific materials in the toolset that support the work and training sessions.

Tool 3.3.1: Small Practice eDesign Curriculum Overview

A high-level look at the SPeDesign learning curriculum, with monthly aggregator and practice tasks and goals for each phase of implementation


Tool 3.3.2: Small Practice eDesign Aggregator Coaching Playbook

A extensive, detailed curriculum of learning community sessions and workshops. The tool includes week-by-week tasks and goals for practices, highlighting tasks aggregators should complete, and roles aggregators should be taking, in order to ensure optimal implementation at each phase. There are also links to external documents that can be helpful in assisting aggregators to engage practices in SPeDesign.

Tool 3.4: Aggregator Technical HandbookThese tools are to help the aggregator implement the technology of SPeDesign. Installation help, FAQs, troubleshooting, and checklists are provided for the aggregator’s technical support team. Unless there is a hyperlink, all 3.4 tools (below) can be found in the Technical Handbook – Tool 3.4.

Tool 3.4.1: SPeDesign Model Software Architecture

Tool 3.4.2: Solo Practice Hardware Configuration

Tool 3.4.3: Network and Connectivity Requirements

Tool 3.4.3.1: athenahealth Technical Requirements

A PDF document detailing minimum technical requirements for athenaCollector

Tool 3.4.3.2: eClinicalWorks Technical Requirements Two documents detailing minimum hardware requirements for eClinicalWorks based on practice size; one document is for practices with one to two providers, and the other is for practices with three to nine providers.

Tool 3.4.3.2a (1-2 providers) Tool 3.4.3.2b (3-9 providers)


Tool 3.4.4: System Integration

Tool 3.4.4.1: eClinicalWorks Charge Specifications

This tool outlines the specification for the eClinicalWorks HL7 charge interface.

Tool 3.4.5: Laboratory Orders and Results

A discussion of the eClinicalWorks electronic Health eXchange (eHX) hub-and-spoke architecture designed to enable the exchange of lab orders and results between practices and any number of clinical laboratories; includes a diagram of the architecture.

Tool 3.4.6: Aggregator Technical Support Model

A diagram and discussion of SPeDesign’s three-tiered approach to providing technical support to participating practices.

Tool 3.4.7: Aggregator Technical Support Roles and Responsibilities

A discussion of what technical support staff aggregators should be prepared to have on staff, hire, or consult with in order to properly support participating SPeDesign practices.

Tool 3.4.8: SPeDesign Technology Lessons Learned and Implementation Hints

Lessons learned from the pilot wave of SPeDesign implementation in Tulare County.


Step 4: Assess, Enroll, and Prepare Practices

Tool 4.0: Overview of Step 4 and Related ToolsThis step has several tools to recruit and engage practices and other providers (such as labs or pharmacies) in the community, as well as the broader patient and business community.

Tool 4.1 offers a set of recruitment communications, such as invitations, emails, announcements, and a presentation for practices including benefits, funding, and competitive EHR options. Tool 4.2 is a survey that aggregators can use to assess the readiness and willingness of participating practices in beginning the SPeDesign implementation process. Tool 4.3 shares the process and the forms practices will need to complete, along with a guide to negotiating on EHR software, and Tool 4.4 shows the vendor contracts that practices will be signing. Tool 4.5 outlines the ideal rollout strategy for practices that have purchased their hardware and software. Tool 4.6 highlights potential community partners, and Tool 4.7 are forms to track staff time usage at the practices and Tool 4.8 provides information on securing a CME credit for the learning community program.

Tool 4.1: Sample Small Practice Outreach Materials

A MS Word document containing sample outreach materials for developing community interest in and support for SPeDesign and recruiting practices to participate; includes meeting invitations and an agenda, and an outreach memo

Tool 4.2: Physician and Practice SPeDesign Readiness Assessment

An interview guide for aggregators to use to gauge the readiness of and interest in participating in SPeDesign

Tool 4.2.1: Practice Staff Computer Skills Checklist

A short checklist to accompany the Tool 4.2 HIT readiness assessment.

Tool 4.2.2: Is Your Practice Ready for Change?

A helpful article from TransforMED : http://www.transformed.com/workingPapers/AssessingChangeReadiness.pdf


http://www.transformed.com/workingPapers/AssessingChangeReadiness.pdf

http://www.fachc.org/pdf/Escaping%20the%20Tyranny.pdf

Tool 4.2.3: Why Does Our Phone Ring?

A spreadsheet for practices to track calls and identify exactly what business calls are generating

Tool 4.3: Practice Agreement Process and Forms

A checklist and set of forms to send to practices to secure payment, and other information to get started with the implementation


Tool 4.4: Vendor Contract InformationSee Tools 2.8.1, 2.8.2 and 2.8.3 for vendor contracts. There are templates of the contract and purchase process for practices to buy hardware and software for the three main vendors - athenahealth, eCW, Dell

Tool 4.4.1: EHR Contract Negotiation Tips

A guide to securing an optimum contract for EHR software

Tool 4.4.2: HIPAA Business Associate Agreement

An agreement between participating practices and any consultants they may hire; authorizes the practice to share data with the consultant and releases the practice from HIPAA liability.

Tool 4.5: SPeDesign RolloutAt this stage, you as an aggregator should have recruited perhaps seven to ten practices to participate in SPeDesign. Participating practices should have completed their baseline data forms and placed orders for hardware and software.

There are two tasks – prepare all the practices and select the practice for the first installation.

The first step in preparing the practices is to get data from each practice on their typical appointments, their hours of operation and staff roles. Each practice will also need to share how their current patient processes; that is how patients check in and out, secure referrals and prescriptions and what technology (if any) the practices uses. These interviews should be conducted by the project manager of the aggregator. There is a set of checklists for use for this purpose.

Tool 4.5.1: Aggregator Action Checklist

A list for the aggregator to use to keep track of the completion of SPeDesign tasks, across Steps 4, 5, and 6 for up to 15 practice sites

Tool 4.5.2: Project Rollout Kickoff Questionnaire

A set of questionnaires that practices should complete before beginning any software installation and implementation, including a checklist of appropriate hardware and software and a questionnaire on current staff roles


Tool 4.5.3: SPeDesign Improvement Projects

A list of individual projects that practices can tackle in the course of using SPeDesign-generated data for ongoing practice process improvements

Tool 4.6: Potential Community Healthcare Partner OutreachA key task of the aggregator is to recruit other community healthcare partners such as labs, imaging centers, pharmacies and others. The practices will need software interfaces to connect data from their practice to these providers. It’s worth noting that pharmacy adoption and use of e-prescribing software can be a significant challenge given the variety of pharmacy retailers in a community from solo-owned “mom and pop” stores to national chains. Aggregators need to be prepared to host meetings with a range of community partners to help assure that the full e-prescribing communication loop can effectively occur (including pharmacy receipt and ability to process e-prescriptions, and the ability to request and receive/process prescription renewals).

Tool 4.7: Staff Activity SurveysThese tools collect information on how each practice’s staff is using its time. This information helps practices see where staff time is going, and where improvements can be made.

Tool 4.7.1: Physician and Nurse Activity Survey

A MS Word document charting how staff time at each practice, including that of physicians, is allocated

Tool 4.8: Providing CME Units

CHCF provided continuing medical education (CME) units to Wave 1 physicians and other clinical staff, who received one unit of CME for each hour of the learning community sessions that they attended. The CME provider was the California Academy of Family Physicians (CAFP). Physicians (MD and DO), nurse practitioners, nurses, and physician assistants are eligible for CME through CAFP.

CAFP requires the completion of a CME workbook (see Tool 4.8.1 – CAFP CME Workbook), which includes:

Accreditation information sheet Letter of agreement Description of CME activities Financial disclosures of faculty

At each SPeDesign learning session, clinical staff signed in and completed an evaluation (see Tool 4.8.2 – SPeDesign Learning Community Evaluation Form and Tool 4.8.3 – SPeDesign Learning Community Sign-in Sheet). CHCF maintained documentation of attendance and summarized the evaluations. The following materials were sent to CAFP after each learning community session:


Agenda Sign-in sheet Evaluation summary Presentation materials

After the final learning session, CAFP would provide the total CME earned by physicians and other clinical staff.

Contact Shelly Rodrigues, CAFP Deputy Vice President, at [email protected] for more information.

Tool 4.8.1: CAFP CME Workbook

A sample of the CME workbook CAFP requires applicants to complete

Tool 4.8.2: SPeDesign Learning Community Evaluation Form

A MS word document for evaluating the learning community

Tool 4.8.3: SPeDesign Learning Community Sign-in Sheet

A MS Word document for tracking learning community attendance


mailto:[email protected]

Step 5: Implement Phase I - Revenue Management

Tool 5.0: Overview of Step 5 and Related ToolsImplementation of the SPeDesign model occurs in two phases - first, the revenue management software, and then the EHR (see Step 6: Implement Phase II – EHR and Workflow).The key outcome from Step 5 is for the practices to learn how to use data to improve their workflow and operations. These skills are essential prior to the EHR installation. The tools here explain the concept of revenue management, provide a detailed manual for the installation of the software, and give case studies on the experiences of the practices in the pilot wave of SPeDesign implementation.

Tool 5.1 gives the overview of revenue management, and Tool 5.1.1 offers a look inside athenaCollector. Tool 5.2 shares a few of the comments pilot wave physicians had to offer regarding implementing a revenue management system. Tool 5.3 gives a thorough outline of the tasks practices, aggregators, and athena will complete during each phase of the implementation. The focus is on the aggregator’s role in shepherding all parties through the process.

Tool 5.4 helps aggregators talk to practices about their current scenarios and desired future states (before-and-after), and looks at anticipated benefits of the new software and the new data-driven approach. The next tools are satisfaction surveys, to be distributed to practice physicians, staff, and patients; these tools are intended to give the aggregators information on what is and is not working in the practices. The tools should be distributed both before and after implementation of revenue cycle management; the follow-up data will help identify areas for improvement in the Phase II implementation of eClinicalWorks. The final tool, 5.8, shows practice feedback reports in athenaCollector, using this software.

Tool 5.1: What is Revenue Management?Revenue management refers to software solutions that assist practices with streamlined billing and collections. Most revenue management systems are Web-based and can be part of a broader practice management system that includes patient scheduling tools, check-in management, coding, referral management, check-out, appointment follow-up, collections, accounting, and reporting. Most revenue management packages have extensive databases of billing rules to ensure payment from health insurers.

The Small Practice eDesign model uses athenahealth’s athenaCollector.

Revenue Cycle Management System (RCMS) goals: Improve amount and speed of payment. Decrease rework and error, enabling saved time to be redirected to patient care and service. Use data to drive improvement in this and subsequent stages of the project.

Practices that implement RCMS will be able to: Use scheduling tools to match patients with the resources required during the visit

(providers + special resources), using an open schedule template and limited appointment types.

Reduce patient no-shows and work with patients to minimize schedule disruptions and delays and maximize patient access.

Minimize claim rework and accelerate and improve revenue capture.


Model workflow that documents the visit during or just following the visit, using discrete diagnosis codes, in preparation for EHR documentation to drive claim creation and collection

Tool 5.1.1: Overview of athenaCollector

A PDF overview of features of athenahealth’s athenaCollector software

Tool 5.2: Pilot Practices’ Experience with Revenue ManagementFollowing are observations from some of the pilot physicians on their experiences implementing the athena revenue management process in their practices.

Providers told the pilot evaluator they were already seeing evidence that the athena revenue management system was improving their practice's billing processes and results.

Nearly every physician considered the new billing system to be an improvement over his or her previous system. When asked what was the best thing that’s happened so far in the implementation, five out of the eight physicians immediately brought up the athena system. Several claimed they were already realizing benefits.

One physician described a significant contrast between athena’s revenue capture processes and the system he has depended on for the last several years: “The best thing that’s happened is also kind of the worst thing: finding out how bad a job the previous billing service was doing. It’s good to know though. We wonder what the previous billing service was doing with some of the data we were giving them. It probably resulted in a lot more right-offs”. He also said that he feels more in control of billing processes with athena: “Athena lets us take more ownership. We’re also learning more about what CPT codes are needed for Medicare and other insurances to make sure we get reimbursed.”

The feature most often cited as beneficial was the immediate feedback the athena system provides on claims: “The best thing that’s happened is…the potential to generate increased revenue and an increased understanding of our billing system. We’re learning about concepts like “kick” and “drop” which I didn’t know about before. I like the immediacy of it. You know before you leave. It’s what I would call contemporaneous. You have a real incentive to get it done before 9 PM Pacific standard Time. It’s a major hassle if you don’t. When I started in practice in 2000 I got some advice to never let anyone else count my money. With this system there may come a time when I can let someone else do it.”

Another physician likened athena’s built-in feedback loop to checking homework before it’s turned in: “It’s like having someone look at your homework before you turn it in. Someone looks at it right then and there so you can make corrections.” One practice is already realizing increased collections: “We have an immediate response to claims and [as a result] I’m seeing the dollars start to flow. Athena is certainly better than the two previous billers I had.”


The new billing system triggered a unique insight for one physician: “Now I have to un-click my head and realize that this is a business I’m running. I didn’t used to care what vaccines cost. But now I realize that some cost more than I’m reimbursed for them.”8

Tool 5.3: Revenue Management Implementation Project PlanA step-by-step guide providing the aggregator with information on how to support practices from installation through effective use of the revenue management tools over the course of sixteen weeks

A revenue cycle management system implementation guide, in MS Word

Tool 5.4: Setting Practice ExpectationsHelps practices understand the data and level of detail that the athena revenue management tool will deliver for a practice. Tool 5.4.1 is a snapshot of the athena dashboard.

The Tulare pilot evaluator reporting on the pilot practices’ desired outcomes: Nearly every physician considered the new billing system to be an improvement over his or her previous system. When asked what was the best thing that’s happened so far in the implementation, five out of the eight physicians immediately brought up the athena system. Several claimed they were already realizing benefits.

Some doctors anticipate increased data-driven efficiencies: “I know I can be more efficient; I know I can see more patients in the same amount of time. I want it to be easier to get people into visits and get them in sooner.” Another anticipates using the data to directly boost efficiency: “I’m hoping the data can help us eliminate the little things that don’t impact patient care.”

Tool 5.4.1: Getting to Green-RCMS Best Practices Checklist A checklist of revenue cycle management system best practices for implementation.

Tool 5.4.1.1: Getting to Green – Best Practices Draft Policies

A chart practices can use to see how close they are to “green,” that is, to achieving full revenue cycle management system success.

8 The Pilot Evaluator’s Report: Interim Summary Report SPeDesign Wave I Physician Interviews January 2010


Tool 5.4.1.2: RCMS Goals

A chart practices can use to see how close they are to “green,” that is, to achieving full revenue cycle management system success.

Tool 5.4.2: athena Sample Practice Performance Review

This is a sample of the kind of practice performance information that athenaCollector can pull together for a practice. A practice that uses the athena data effectively can be expected to increase revenue and efficiency.

Tool 5.4.3: athena Sample Physician Performance Review

This document measures an individual physician’s or clinic’s performance against athena’s established best practices. This data will identify areas where a physician could benefit from improvement efforts, and should, again, eventually contribute to increased revenue and efficiency.

Tool 5.4.4: Abstraction Time Planning Calculator

MK – I need a blurb for this document. I have no idea what it’s measuring. NJB

Tool 5.5: Physician Satisfaction Tool

A MS Word survey that measures a physician’s satisfaction within his or her practice; before and after results can evaluate whether or not the athena implementation was successful, and can identify areas to improve the implementation process for eCW

Tool 5.6: Practice Staff Satisfaction Tool

A MS Word survey that measures the satisfaction levels of the staff at each practice


Tool 5.7: Patient Satisfaction Tool

A two-page survey that measures patients’ satisfaction and suggestions for improvement, at their respective physician offices

Tool 5.8: Tools for the Learning Community CurriculumThe tools in Tool 5.8 provide background reading in preparation for implementing the Step 5 work of the learning community curriculum.

Tool 5.8.1: Anatomy of a Huddle

A PDF of the article: http://www.coloradoguidelines.org/pdf/ipip/learningcollaborative/june2009/greenmtn/saturday/23a.%20How%20to%20do%20Team%20Huddles%20-Anatomy%20of%20a%20Huddle%20Handout.pdf

A video on team huddles: http://www.youtube.com/watch?v=Wttxm7jAnb4

A CHCF video on team meetings: http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=133956

Tool 5.8.2: Escaping the Tyranny of the Urgent by Delivering Planned Care


Tool 5.8.3: Creating a High-Performance Clinical Team

An AAFP article: http://www.aafp.org/fpm/2006/0300/p38.html

Tool 5.8.4: Great Tips for Patient Scheduling

http://ezinearticles.com/?Great-Tips-For-Patient-Appointment-Scheduling&id=2088103


http://ezinearticles.com/?Great-Tips-For-Patient-Appointment-Scheduling&id=2088103

http://www.aafp.org/fpm/2006/0300/p38.html


http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=133956

http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=133956

http://www.youtube.com/watch?v=Wttxm7jAnb4

http://www.coloradoguidelines.org/pdf/ipip/learningcollaborative/june2009/greenmtn/saturday/23a.%20How%20to%20do%20Team%20Huddles%20-Anatomy%20of%20a%20Huddle%20Handout.pdf



Step 6: Implement Phase II - EHR and Workflow Changes

Tool 6.0: Overview of Step 6 and Related ToolsStep 6 is the implementation of the eClinicalWorks electronic health record software. The primary tool is an overview of the eClinicalWorks software and Tool 6.2 is a detailed step-by-step guide for aggregators to use in coaching practices through eCW installation to the full use of the software and the dashboard of metrics.

Tool 6.1: Overview of eClinicalWorksExplains the eClinicalWorks product

An overview of eClinicalWorks

Tool 6.2: eClinicalWorks and ELINCS ImplementationThis is a set of tools intended to help laboratories and medical practices plan and manage the implementation of an electronic lab interface based on the ELINCS ambulatory care lab result message specification format.

Tool 6.2.1: ELINCS HL7 Release 1 (HL7-R1) Interface Implementation Guide

This guide was developed by Sujansky and Associates, and details the processes involved in interfacing a practice’s electronic health record with ELINCS. The guide is written for general application, but for SPeDesign purposes the EHR software will be eClinicalWorks. The guide highlights specific tools to help laboratories, vendors, and aggregators with the implementation of an ELINCS-compliant electronic lab results interface.

The guide also features a list of reference laboratories and EHR and disease registry vendors that support ELINCS HL7-R1; eClinicalWorks is one of these vendors.

Tool 6.2.1.1: ELINCS HL7-R1 Interface Project Plan

A spreadsheet-based project plan that lists the tasks and sub-tasks necessary for implementing a bidirectional lab interface with ELINCS.

Tool 6.2.1.2: EHR Implementation Test Script

A test script document that will guide EHR vendors through using the ELINCS EDGE tool software unit to test their ELINCS interfaces and EHR applications before testing with a lab


interface partner. eClinicalWorks supports ELINCS HL7-R1, and so is already prepared to guide practices through the process.

Tool 6.2.1.3: ELINCS HL7-R1 Lab Result Interface Test Plan

A test plan for EHR vendors and laboratories to use for the implementation test phase of a lab interface project. The goal of the testing at this point is to verify that ELINCS lab interface requirement have been met.

Tool 6.2.1.4: ELINCS HL7-R1 LOINC Codes

A spreadsheet containing a subset of the LOINC database; the codes in this subset are specifically pertinent to ELINCS results reporting.

Tool 6.2.1.5: ELINCS HL7-R1 Specification Review

A PowerPoint presentation highlighting the salient features of the ELINCS ambulatory care lab result messaging specification.

Technical assistance to assist aggregators, laboratories, and vendors with implementation of ELINCS is available at http://sujansky.com/elincssupport.php . Sujansky and Associates is a healthcare informatics consulting firm originally contracted by the California HealthCare Foundation to develop the ELINCS specification.

Tool 6.3: eClinicalWorks Implementation TipsThese tools offer helpful suggestions on refining the implementation of eClinicalWorks.

Tool 6.3.1: Prepping for eCW Go-Live

Some helpful reminders to practices to keep in mind

Tool 6.3.2: Results Management Tip Sheet

Some tips to maximize the benefits of the eCW alerts and CDSS


http://sujansky.com/elincssupport.php

Tool 6.3.3: Getting Ready for the Patient Portal

Some tips to help practices prepare to use the eCW patient portal


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