Meaningful Use Stage 2 (Part
2) – Patient Engagement, HIE and TOC
Adele AllisonNational Director of Government Affairs
October 25, 2012
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4 Marks of Meaningful Use
Adopt and Adopt and Use CEHRTUse CEHRT
Capture Capture DATADATA
Report Report DATADATA
Move Move DATADATA
888.879.7302 • www.SuccessEHS.com
4 Marks of Meaningful Use
Adopt and Adopt and Use CEHRTUse CEHRT
Capture Capture DATADATA
Report Report DATADATA
Move Move DATADATA
Core: Rx
CPOE
Core: Rx
Alerts
Core: Problem
List
Core: eRx
Core: Rx List
Core: Rx
Allergy List
Core: Demo-
graphics
Core: Vitals
Core: Smoking
Status
Core: CQMs
Core: Clinical
Decision Support
Core: eCopy
of Record
Core: Clinical
Summary
Core: Test of
Exchange
Core: Protect
PHI
Menu:Rx
Formulary
Menu:Lab
Results
Menu:Patient Lists
Menu:Patient
Reminders
Menu:Patient
eAccess
Menu:Patient Education
Menu:Rx
Reconcile
Menu:TOC
Summary
Menu:Immun. Registry
Menu:Syndromic
SurveillanceData
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4 Marks of Meaningful Use
Adopt and Adopt and Use CEHRTUse CEHRT
Capture Capture DATADATA
Report Report DATADATA
Move Move DATADATA
Core:CPOE
(Rx, Lab and Radiology)
Core:Demo-
graphics
Core:eRx and Formulary
Core:Vitals
Core:Smoking
Status
Core:5 CDS and Rx Alerts
Core:Lab
Results
Core:Patient Lists
Core:Patient
Reminders
Core:Patient View,
Download, Transfer
Info
Core:Clinical
Summary (Electronic &
Paper Avail.)
Core:Secure
Messaging w/
Patients
Core:Reconcile
Rx
Core:TOC
eSummary of Care Record
Core:Production
Immun. Reporting
Core:Protect
PHI (Encryption)
Menu:Production
Imaging Results
Menu:Family Health History
Menu:Electronic
Notes
Menu:Production eSyndromic Surveillance
Menu:Production
Cancer Registry
Reporting
Menu:Production Specialized
Registry Reporting
CQMs:Electronic Reporting (EHR Direct Preferred)
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4 Marks of Meaningful Use
Report Report DATADATA
Move Move DATADATA
Adopt and Adopt and Use CEHRTUse CEHRT
Capture Capture DATADATA
• Cultural Shifto Change is hard → “We’ve
always done it this way.”o Leadership and Professionalism
• Redesign will create temporary Chaos
• Address techno-challenged userso Scribeso Focused trainingo Super-users
• Celebrate your success!
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4 Marks of Meaningful Use
Capture Capture DATADATA
• Workflows must be consistent
• 3 Data-entry Types1. Narrative Text2. Structured Data3. Object-oriented, Codified Data
• Apply the 5-Rights1. Right Information2. Right Person Capturing3. Right Data Format4. Right Technology Channel5. Right Time in Workflow
Adopt and Adopt and Use CEHRTUse CEHRT
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4 Marks of Meaningful Use
Capture Capture DATADATA
Move Move DATADATA
• Define your Use Cases o Referral Managemento ED/Hospitalization Notificationo Emergency – “Break-the-Glass”o New/Unknown Patient
• Use Cases → 2 Clear Goalso ↑ Qualityo ↓ Costs
• Interface vs. HIE• Health Information
Exchangeo Sustainability Modelo Emerging Technology
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Move Move DATADATA
4 Marks of Meaningful Use
Report Report DATADATA
• Clinical Data Reporting is Crucial!o Drive Reimbursement Reform
under ACA (E.g. VBM)o Physician Compare Website
• CQMs to be electronically submitted by CY2014
• Medicare Data → PQRSo Claims-basedo Registry-basedo EHR Direct
• Medicaid Data → Ind. Stateo Process and Timelineso Interface or HIE
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MU2 Health IT Implementation List
• CPOE• Rx Database• Master Patient Index• Patient Administration• Detailed Vitals• Smoking Status• Population Health Mgmt.• Thin-Client Operations• Data Encryption Technology• Internet Enabled Technology• Structured Knowledge Base• Documentation Tools
• eRx, Rx History and Formulary (E.g., Surescripts / RxHub)
• Evidence-based Guidelines• Advanced Patient Portal• Patient Education• HIE → Direct / Exchange• Bidirectional Lab Interface / HIE• Immunization Interface / HIE• PACS Interface / HIE• Public Health, Cancer and/or
Specialty Registry Interface / HIE• Hosting / Emergency Backup
CEHRT Standard Offerings
CEHRT Extensions
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Plugging into the Matrix
• Americans are plug into the Matrix more than ever• 88% Age 18+ have a cell phone (77% of Rural Residents)
• 67% Texting → Dominates, especially with Teenso 75% of all Teens text
o Teens average 60 texts per dayo GirlsGirls text more than boys at 100 / day compared to 50 / day
o Black teens text average of 80 / day
• 57% have a Laptop• 19% have a Tablet Computer• 19% Own and e-book Reader
• 52% Adult Americans use phones while watching TV
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Plugging into the Matrix• Who: 76% Internet Use in U.S. → Ubiquitous and
Pervasiveo 4.7% Dial-upo 63.5% Broadband
• What: Internet Usageo 62% Social Networkerso 55% Share Photoso 26% Comment / Blogo 15% Personal Websiteo 12% Tweet
• Elderly: 53% of Age 65+ use Internet / Emailo 39% have Broadbando Only 34% of Age 75+ have Internet
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Plugging into the Matrix
• The Matrix has impacted Patients and Health Care• 61% Age 18+ get Health Information Online
o 88% of Caregivers look online for health info
• 19% Source Provider Rankings / Reviewso 5% Post Themo CMS → Physician Compare www.medicare.gov/find-a-doctor/provider-
search.aspx
• 18% Source Hospital Reviewso 4% Post Themo CMS Hospital Compare www.hospitalcompare.hhs.gov
• 14% of Patient sign-up for alerts• 7% have health apps on handhelds
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Patient Engagement Principles
• Requires real change by both Providers and Patients• 2 Golden Rules of Patient Engagement
1. Patient Experience best measure of patient engagement, and
2. Solicit Patient / Family Involvement in how the practice should work for them.
• Research → Better Experience = Better Outcome• Patient Involvement → Advisory Councils, Focus
Groups, Input = Patient-designed Care Process
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Plugging into the Matrix
• Is Patient Decision-making Affected? Yes!• 49% Influences view of diet, exercise, stress mgmt.• 38% Affected decision about seeing a doctor• 38% Altered way of coping with Chronic Condition / Pain
Area of Advice Sought
ProfessionalFamily, Friends, Fellow Patients
Both Equally
Accurate Diagnosis 91% 5% 2%Rx Information 85% 9% 3%Alternative Treatment 63% 24% 5%Specialist Recommendation 62% 27% 6%
Hospital Recommendation 62% 27% 6%
Illness Emotional Support 30% 59% 5%
Quick Remedy for Health Issues
41% 51% 4%
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Fed. Programs & Patient Engagement • Behavioral Economics requires an Engaged Patient
o Effects of social, cognitive, emotion factors on patient decision-makingo E.g., Airport McDonalds Story
• Transition from Episodic Care to Long-Term Healing and Wellness
• Research → Patient Engagement ↑ Quality and ↓ Costs• 4 Federal Initiatives with Patient Engagement Regulations
o Meaningful Use Stage 2 - 7 Measureso Accountable Care Organizations – 7 Measures7 Measureso NCQA Patient-Centered Medical Home – 66 Factorso Value-based Purchasing – CAPHS
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Fed. Programs & Patient Engagement
Proposed Stage 2 Core MeasuresNo. Objective Measure Threshold Exclusions
1Implement Clinical Decision
Support and Track Compliance
Implement CDS to improve on high-priority condition:1.5 CDS interventions for 5 or more CQMs during entire reporting period; and2.Enable drug-drug and drug-allergy checks for entire reporting period.
5 Rules and Rx alerting by attestation
None
2Provide Patients with Clinical
Summaries
For each office visit to patients within 24 hours, which includes up-to-date lists of problems, medications and Rx allergies (paper and electronic must be avail. to pt.)
50% (Unchanged)
EP has no office visit during EHR reporting period
3Use EHR for Patient-Specific
Education ResourcesProvide patient-specific education resources to all patients
10% (Unchanged but made Core and “if
appropriate removed)
EP has no office visit during EHR reporting period
4Generate Lists of Patients by
Condition
1 List with a Specific Condition for use in quality improvement, reduction of disparities, research or outreach
By attestation (Made Core) None
5Use of secured messaging with
PatientsSend secured messages to patients seen during reporting period
10%EP has no office visit during EHR reporting period
6Timely Electronic Access to Health
Information
Patients can view online, download and transfer info within 4 days of being available to EP, subject to EPs discretion to withhold certain info
1. 50% of all pts., and
2. 10% of pts. access
EP has no orders / creates info required
>50% visit in county with >50% with 4Mbps broadband avail.
7 Send Reminders to PatientsPreventative and follow-up care for all patients based on clinically relevant info for anyone with an OV in past 24 months
10% (↓ from 20%, all patients and Made
Core)
EP has no office visit in previous 24 months
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ACOs and Patient Engagement Engagement
• 3333 Quality Performance Measures Quality Performance Measures • 77 Patient / Caregiver Experience Patient / Caregiver Experience
• Final Rule requires CMS qualified Survey Vendor by 2014Final Rule requires CMS qualified Survey Vendor by 2014• HITPC Preliminary HITPC Preliminary Stage 3Stage 3 Draft Draft (Aug (Aug →→ Final Recommendations expected Final Recommendations expected
in Nov)in Nov)o Patients Option to submit data online Patients Option to submit data online →→ 10%10% submit submit Medical HistoriesMedical Historieso Patient Patient educationeducation in in non-English languagesnon-English languageso 10%10% of Patients ability to of Patients ability to update update and and correct information correct information onlineonline
Measure Method of Data SubmissionGetting Timely Care, Appointments and Information SurveyHow Well Your Doctors Communicate SurveyPatients’ Rating of Doctor SurveyAccess to Specialists SurveyHealth Promotion and Education SurveyShared Decision-Making SurveyHealth Promotion and Education Survey
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PCMH and Patient Engagement
• Affordable Care Act mentions Medical Home 15 Times• ACA references Patient-Centeredness 36 Times• NCQA now offers a new Distinction in Patient Experience
o Optional with PCMH Recognitiono “Consumer Experience is Critical Component of Quality of Care”o Uses CAHPS PCMH Survey to access:
Access Information Communication Coordination of Care Comprehensiveness Self-Management Support and Shared Decision-Making
PointsNCQA PCMH 2011
Standard and ElementNumber
of FactorsMust Pass?
20 PCMH Standard 1: Enhance Access and Continuity 344 Element A: Access during office hours 4 Yes4 Element B: Access after hours 5 No2 Element C: Electronic Access 6 No2 Element D: Continuity 3 No2 Element E: Medical Home Responsibilities 4 No2 Element F: Culturally & Linguistically Appropriate Services (CLAS) 4 No4 Element G: Practice Organization 8 No
17 PCMH Standard 2: Identify and Manage Patient Populations 353 Element A: Patient Information 12 No4 Element B: Clinical Data 9 No4 Element C: Comprehensive Health Assessment 10 No5 Element D: Using Data for Population Management 4 Yes
17 PCMH Standard 3: Plan and Manage Care 234 Element A: Implement evidence-based guidelines 3 No3 Element B: Identify High-Risk Patients 2 No4 Element C: Manage Care 7 Yes3 Element D: Management Medications 5 No3 Element E: Electronic Prescribing 6 No9 PCMH Standard 4: Provide Self-Care and Community Support 106 Element A: Self-Care Process 6 Yes3 Element B: Referrals to Community Resources 4 No
18 PCMH Standard 5: Track and Coordinate Care 256 Element A: Test Tracking and Follow-up 10 No6 Element B: Referral Tracking and Follow-up 7 Yes6 Element C: Coordinate with Facilities / Care Transitions 8 No
20 PCMH Standard 6: Measure and Improve Performance 224 Element A: Measures of performance 4 No4 Element B: Patient / Family feedback 4 No4 Element C: Implements Continuous Quality Improvement 4 Yes3 Element D: Demonstrates Continuous Quality Improvement 4 No3 Element E: Performance Reporting 3 No2 Element F: Report Data Externally 3 No
100 149 6
66 Direct Patient
66 Direct Patient
Engagement Framework
Engagement Framework
FactorsFactors
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VBP & Patient Engagement • Hospitals subject to CMS payment adjustments based on
patient experience• Starts October 1, 2012• Evaluated / Scored on performance improvements over
baseline• Patient Experience measured by HCAHPS scores• Hospital staff undergoing patient satisfaction, customer service
and communication training• Results published on Hospital Compare website• ACA has Physician VBM program starting in 2015 based on
2013 performance• Physician Compare website now in place to show performance
metrics - first publishing (limited) in CY2013
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Communication Shift• Patient Portals have existed since 1990
o Patient Engagement was transactional – Financial Focuso 56M accessed records through Patient Portal (Oct 2011)
• Paradigm shift in the way health information disseminated
Pull Information Model
Push Information Model
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Patient Portal a MUST• Patient Engagement requires a Patient Engagement requires a Willing PatientWilling Patient• Patient Portals Patient Portals → → Contagious Contagious and and Effective ToolsEffective Tools• Hub of the Patient, Family, Provider and Staff Hub of the Patient, Family, Provider and Staff CommunicationCommunication
o Web-basedo Secure communication channel with clinicianso Facilitates appointments and Rx renewal
• ImplementationImplementation Considerations Considerationso Incorporated on Practice or stand-alone website?Incorporated on Practice or stand-alone website?o Separate license cost (3rd party product)?o Integration requirements?o Browser compatibility (E.g. Microsoft Explorer, Mozilla Firefox)o Setup, configuration and trainingo Patient Password management
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Who has ever used an ATM?
Health Information Exchange (HIE)
Transferring of data accurately from one healthcare venue to another.
What is interoperability?
Why is Interoperability so hard to achieve in Healthcare?
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ATM Banking vs. Healthcare
ATM Healthcare
Bank to Bank
Account #
Location
Balance
Withdraw Amount
Hospitals
Individual Physicians
PharmaciesLabs
Payers
Public Health Authorities
Patient DemographicsPayer InfoMedications
Lab Results
AllergiesImmunizations
Vitals
Family HistorySocial History
Clinics
Procedures
Diagnostic Center
Nursing Home
Student Health Center
Behavioral Health Dentists
Mental Health
Images
Consult Reports
Discharge Summaries
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Challenges causing Healthcare Interoperability to be so hard to achieve.
Variability of Applications (standards)
Funding
Processes and Document Types
Semantics and Complex Vocabulary
Privacy and Security
Free text vs. Discrete Information / Data
Interoperability Challenges
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HIE Success Factors• Early efforts → Some succeeded, some failed • Today → Same success factors apply
Success Factors
Shared Vision with stakeholders
Incremental Approacho Limited initial goalso Build on pilots
Uninterrupted physician workflow
Internet Technology
Strong commitment to Medical Informatics
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HIE Guiding Principles
1. Improve Patient Care
2. Increase Operational Efficiency to lower clinic costs
Guiding Principles
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Use Cases and Transport Options
Examples
Alerting PCP to ED Visit
Transitions of Care
Referral Management
Query for Documents
HIE Options
Direct
Exchange/XDS
Custom HL7 messages
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Direct Example → Referral Management
Consult Referral
Consult Report
Arrhythmia
Jane Doe
Dr. Smith(Internist)
Dr. Heart(Cardiologist)
HISP
HISP
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Exchange/XDS Example → Car Accident
CCD RequestCCD
published John Doe
Dr. Smith(Rural Health)
EmergencyUrban Center
HIEHIE
CCD Response
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Custom HL7
Custom HL7
Not Meaningful Use Eligible
Custom Development Required
Impacts Cost and Speed of Roll-Out
Typically, evaluated on Case-by-Case Basis
Established pre-IHE Standards → Long-Established HIEs DO NOT use IHE Industry Standards
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What is a “Transition of Care?”• Movement of patients from
one provider or setting to another
• Occurs at multiple levelso Within Settings
Primary care Specialty care ICU Ward
o Between Settings Hospital Sub-acute facility Ambulatory clinic Senior center Hospital Home
o Across health states Curative care Palliative
care/Hospice Personal residence Assisted living
(c) Eric A. Coleman, MD, MPH
Referral
Discharge
ALF / SNF
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Outpatient
TOC Potential Issues
Patient
ER ICU
In-Patient
Patient
SNF ALF
Personal Medicine List?
Coordinated Care Plan?
Medication Reconciliation?
• Home• PCP• Specialty• Pharmacy• Case Mgr.• Care Giver
Inpatient Discharge Plan?Medication
Reconciliation?Personal Medicine
List?
DischargePlan?
Care Plan?Medication
Reconciliation?Personal Medicine
List?
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TOC and Outcomes• Problem: 75% of PCPs → No info about a patient’s
hospitalization post-discharge = Readmissions• Ineffective Transitions Ineffective Transitions → Poor Outcomes and Increased Costs
o 1:5 Seniors (2.6M) readmitted within 30 days of dischargeo 2011 Poor Transitions → $25-45 Billion in wasteful spending
• Hospitalization Hospitalization CareCare GapsGapso Discharge Rx Reconciliationo Lack of Understanding of Discharge Plan of Careo Non-compliance or Untimely Post-discharge Plan of Careo No appointments with a PCPo Logistics (E.g. Transportation)o PCP unawareness of hospitalizationo Lack, delay or inadequate communication with downstream providero Lack or inadequate communication with home care provider (includes family)
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MU2 and TOC / Referrals – 3 Tasks• 1 Core Measure / 1 Task → Rx Reconciliation during TOC - 50%• 1 Core Measure / 2 Tasks → Summary of Care Record for
TOC/Referralso 50% of TOCs / Referrals
- AND -o 10% electronically transmitted
• Summary of Care Record Core Hospital/CAH measure, as well• CMS Alignment → Critical to ACO Performance Gains
o 10% Improvement in DM Measures = 1% Reduction in Costso Conclusion: Care Coordination focus a “Must” for sustainable ACO
performanceo 6 ACO Performance measures link to care coordination
• TOC / Referral success will rely upon HIE
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MU2 and TOC / Referrals – CEHRT
CEHRT Must• Receive Information• Display in Human-
Readable Format• Accept CCD, CCR and/or
CCDA• Incorporate Rx, Allergies
and Problems• Transport Vehicle: Direct
• Will CEHRT help match correct patient?
Inbound TOC / Referral
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MU2 and TOC / Referrals – CEHRT
CEHRT Must• Create the Order• Create CCDA (Contains
elements for Inbound TOC requirements)
• Provider Directory (Standard Not Defined in Regulation)
• Connect to HISP• Send CCDA• Possible Receipt of
Record Confirmation
Outbound TOC / Referral
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Stage 2 MU – Infrastructure Wave
Health IT Considerations
Tips for Success
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5 Tips for Success – Patient Engagement• Tip 1: Measure Patient Satisfaction Pre- and Post-Project• Tip 2: Involve the Provider(s)
o They must drive the medical responseso They are going to get mad with some survey results
• Tip 3: Address Cultural-Change Challengeso “One more thing I have to do!”o “Our patients will never go online”o Creates a mutual interdependence between Providers and Patients
• Tip 4: Add a “filter” and Map the Workflowo Make the workflow someone’s job (Think “Care Team”)o Get Providers into a routine (E.g. See patients, answer emails / flags,
cycle again)o Perhaps schedule time on the Provider’s calendar
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5 Tips for Success – Patient Engagement• Tip 5: Promote, Promote, Promote!
o Refine the Message → Faster way to get lab results, refills, etc.; No more Phone-Tag!
o Strategically place Brochures (E.g., Ck-in / Ck-out, Waiting Room)o Add information on appt. reminder cards → “Use our online
scheduling!”o Remind patients of ability to request refills online when they call for
refillso Computer in waiting room to assist patients in registering, completing
paperwork, etc.o Replace “on-hold” music with introduction to patient portalo Add-on announcements with all statements, newsletters and
ePublicationso Improve organizational branding
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5 Tips for Success – HIE and TOC
• Tip 1: Define your Use Caseso Does it improve quality?o Does it decrease costs?
• Tip 2: Involve the Stakeholderso Hospitalo Specialty Providers
• Tip 3: Understand your HIE Marketo Statewide / Local Market Progress and Barrierso HISP Providers for Directo Exchange for more advance Query / Retrieve HIE
• Tip 4: Allow ample bandwidth to plan and implemento Data-Sharing Agreements, SOWo Understand related Costs
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6 Health IT Tips – Your IT Vendor
• Tip 1: Meaningful Use, PQRS and Other Meaningful Use, PQRS and Other DashboardsDashboards??o Metrics / Analytics by ProviderMetrics / Analytics by Providero Facilitates quick numerators/denominators for MU attestationFacilitates quick numerators/denominators for MU attestationo Clinic analytics with drill-through detailsClinic analytics with drill-through details
• Tip 2: Patient Portal Patient Portal Inherent with System?Inherent with System?o Should be part of Core OfferingShould be part of Core Offeringo Avoids Additional vendor and integration considerationsAvoids Additional vendor and integration considerations
• Tip 3: Single database Single database solution for PM and EHRsolution for PM and EHR• Tip 4: EHR Direct EHR Direct PQRSPQRS• Tip 5: More than just first call More than just first call supportsupport
o Initiative Toolkits (E.g. MU, PCMH, PQRS)Initiative Toolkits (E.g. MU, PCMH, PQRS)o Consulting Support with domain expertsConsulting Support with domain experts
• Tip 6: Ongoing Client Educational Ongoing Client Educational OfferingsOfferings
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