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pdfMarch 2011
Barriers to Meaningful Use of
Electronic Health Records
in Medicaid
Pilot Focus Groups—Observations,
Findings, and Recommendations
Prepared for
Heather Johnson
Center for Primary Care, Prevention, and Clinical Partnerships
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Prepared by
RTI International
and
West Virginia Medical Institute
RTI International
3040 Cornwallis Road
Research Triangle Park, NC 27709
RTI Project Number 0210943.002
RTI Project Number
0210943.002
Barriers to Meaningful Use of
Electronic Health Records
in Medicaid
Pilot Focus Groups—Observations,
Findings and Recommendations
March 2011
Prepared for
Heather Johnson
Center for Primary Care, Prevention, and Clinical Partnerships
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Prepared by
RTI International
and
West Virginia Medical Institute
RTI International
3040 Cornwallis Road
Research Triangle Park, NC 27709
_________________________________
RTI International is a trade name of Research Triangle Institute.
Contents
Section
1.
Page
Executive Summary
1-1
1.1 Purpose of Pilot Study ............................................................................. 1-1
1.2 Summary of Findings Based on Pilot Study ................................................ 1-1
2.
Evaluation of Recruitment Processes
2-1
2.1 Recruitment Methods .............................................................................. 2-1
2.2 Observations and Lessons Learned ........................................................... 2-1
2.2.1 Reaching Individual Subjects to be Screened .................................... 2-1
2.2.2 Participant Screening Instrument .................................................... 2-2
2.2.3 Recruiting Individual Subjects to Participate ..................................... 2-3
2.3 Recommendations for Main Study Recruitment Processes ............................. 2-4
3.
Evaluation of Focus Group Format and Content
3-1
3.1 Pilot Focus Group and Interview Methods ................................................... 3-1
3.2 Observations and Lessons Learned ........................................................... 3-1
3.2.1 Composition of Focus Groups ......................................................... 3-1
3.2.2 Focus Group Mode, Setting, and Materials ........................................ 3-2
3.2.3 Moderator’s Guide ........................................................................ 3-4
3.3 Recommendations for Main Study Focus Group Format and Content .............. 3-7
4.
APPENDICES
A. Screening Instrument, version dated November 5, 2010
B. Moderator's Guide, version dated November 5, 2010
C. Show Cards
iii
Tables
Number
Page
Table 3-1.
Composition of Pilot Focus Group Sessions ....................................... 3-2
Table 3-2.
Original Focus Group Configuration* ............................................... 3-8
Table 3-3.
Revised Focus Group Configuration ................................................. 3-9
iv
1. EXECUTIVE SUMMARY
1.1
Purpose of Pilot Study
The purposes for conducting this pilot test are to:
Assess effectiveness of the Moderator’s Guide that will be used in the study’s focus
groups before proceeding with the design and validation of a final Moderator’s Guide.
Assess the effectiveness of various approaches to conducting the focus groups,
including in-person focus groups, virtual focus groups, and one-on-one informant
interviews.
Assess methods for identifying and recruiting focus group participants.
Assess whether and how focus group composition across different types of clinicians
and different levels of experience with electronic health records (EHRs) affects data
collected.
1.2
Summary of Findings Based on Pilot Study
Based on a final analysis of the pilot process the following findings are submitted for
consideration:
The Moderator’s Guide (dated November 5, 2010) will require minor
revisions/refinements. The content and form of the questions were generally clear,
concise, and sufficiently descriptive to generate responses. Questions flowed well and
encouraged a comfortable exchange among and between the facilitator and
participants.
The structure and organization of the Moderator’s Guide should be modified to better
accommodate the various techniques (in-person focus group, virtual focus group,
and one-on-one informant interviews as may be applicable) that will be used.
It is not necessary that focus groups be configured to separate health care providers
who practice in a federally qualified health center (FQHC) or private practice. These
providers may be interviewed during the same sessions.
Both in-person and virtual phone sessions were effective in securing provider
responses.
The identification of prospective participants is a very labor-intensive and timeconsuming process. Multiple contacts/follow-up calls, etc. will need to be made to
confirm interest and to schedule a time to screen the health care provider for
participation. Meeting organizers should expect additional challenges in identifying,
screening, and enrolling providers who do not have an EHR system. Expect that
these types of providers may not be particularly interested in participating in the
study.
A more direct and clear message regarding the scope, Medicaid orientation, and
purpose of the study should be conveyed during the screening process. The
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Barriers to Meaningful Use of Electronic Health Records in Medicaid
Screening Instrument (dated November 5, 2010) should be edited to ensure health
care providers understand the Medicaid orientation. This point should be reinforced
in all subsequent communications/exchanges leading up to the scheduled focus
group meeting.
1-2
As possible, recruiters should attempt to match participants in focus groups based on
level of experience with EHR. There was a definite difference in the amount of
information gathered when the focus group had a more homogenous composition
and everyone was able to relate to a set of like experiences related to EHR use or
non-use.
2. EVALUATION OF RECRUITMENT PROCESSES
2.1
Recruitment Methods
The ultimate success of the study is dependent upon recruiting a diverse, informed, and
engaged group of participants. Each participant must understand the scope, purpose, and
Medicaid orientation of the research and the importance of their responses to arriving at a
final set of conclusions and actionable recommendations that can be submitted to the
Agency for Healthcare Research and Quality (AHRQ).
For purposes of the pilot test, a list of potential study participants was secured from several
sources, including providers known to be State Medicaid participating providers, providers
who had either executed Regional Extension Center (REC) participation agreements or were
likely to do so, and various professional associations that offered suggestions and
recommendations. Relying on these sources, 28 potential candidates were identified for the
pilot study.
The most challenging aspect of the pilot recruitment process was securing participation
commitments from providers not currently using or planning to acquire an EHR system. A
majority of the health care providers not using an EHR system who were contacted did not
seem to recognize or understand the value of their participation in the project. Several
mentioned that if the effort does not offer short-term benefit, they did not understand why
they should take the time to participate. This challenge may be confronted by meeting
organizers as they attempt to secure participants for the main study.
The $200.00 gift offered to each focus group participant appears reasonable for the effort
and time requested, provided sessions are concluded within the 2-hour target range. None
of the participants requested additional compensation. The only exception was the response
received from physicians who did not plan to acquire an EHR system. Several providers
commented that the $200.00 gift did not seem a sufficient incentive for the time requested.
These providers ultimately elected not to participate in the pilot test. However, the amount
of the gift was not necessarily the key factor driving their decision. Time and a lack of
personal interest in the project seemed to be the more significant factors contributing to
their decision.
2.2
Observations and Lessons Learned
2.2.1 Reaching Individual Subjects to be Screened
Main Finding. Rarely will an initial call result in the meeting organizer making direct
contact with the health care provider and completing the Study Screening Instrument. In
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Barriers to Meaningful Use of Electronic Health Records in Medicaid
most instances a specific date/time will need to be scheduled for the Screening Instrument
to be completed. Time should be allowed for scheduling conflicts.
Recruiters will need to be persistent in their outreach efforts. During the pilot study most
health care providers were not immediately available to receive a call nor had the time to
complete the Study Screening Instrument when the initial contact was made. In almost all
cases a specific follow-up date and time was scheduled with the provider to complete the
Screening Instrument. Health care providers do not generally appreciate “cold calls,” and
their daily office schedules rarely afford them the time required to complete the Screening
Instrument, unless advance notice and a scheduling arrangement has been made.
Frequently, the initial call will be routed to a voice mail/messaging system or an
administrative person. Follow-up calls will almost always be required to schedule a
date/time for completion of the Screening Instrument. If possible follow-up calls should be
made during non-office/clinic hours. Typically, the person receiving an incoming call can
establish a date and time most convenient for the provider to be reached. Being
conscientious and considerate of work hours and a provider’s limited availability will create a
positive impression for the subsequent completion of the Screening Instrument.
E-mail messaging was not particularly effective as an initial means of introducing the project
to a prospective participant. It was difficult to secure a correct e-mail address; messages
were not routinely answered in a timely manner; and in most instances, a follow-up call to
introduce the project was required. Although not a particularly effective tool for initial
contact, e-mail messaging is clearly the preferred means for communicating once a
commitment to participate in a focus group is made. Use of e-mail is more time efficient for
the meeting organizer and provider and less disruptive to the office practice/clinic operation.
2.2.2 Participant Screening Instrument
Main Finding. Participants who state that they have an EHR system in place should be
screened to confirm they have a basic familiarity with that system and its potential
functionality. The more familiar a provider is with an EHR system, the more substantive
comments, observations, and opinions they can offer.
The Draft Focus Group Participant Screening Instrument (dated November, 5 2010) was
used to gather information about prospective focus group members and to provide a
preliminary overview of the project. The Screening Instrument should include additional
information that emphasizes the scope and Medicaid orientation of the study. Since this tool
drives the first formal exchange between a project representative and prospective
participant, it is critical that a positive tone and perception of the project be created.
2-2
Section 3 — Evaluation of Focus Group Format and Content
Securing as much information about the targeted health care provider in advance of the call
may reduce the time required to complete the Screening Instrument. This information may
be validated during subsequent contact, and this approach may convey a unique and
genuine interest in a provider’s possible project participation.
Consideration should be given to deleting certain questions in the Instrument that either
duplicate a question in the Moderator’s Guide or may not have particular relevance to an
individual’s participation in a focus group (i.e., Screening Instrument items 10 and 11).
Question 11, for example, reviews use of a listing of specific functions and is better suited
for the focus group session. The Screening Instrument and the Moderator’s Guide should be
reviewed and any data element that will not be collected and retained for analytical or
reporting purposes should be deleted.
2.2.3 Recruiting Individual Subjects to Participate
For the pilot, we identified a pool of 28 potential participants. During the recruitment
process six were not available or did not return our messages. A total of 22 different
providers were contacted about their interest in participating in a pilot focus group. This
included 12 physicians, 4 nurse practitioners or certified nurse midwives, 3 dentists, and 3
administrators. For the Pilot we ultimately recruited a total of 9 individuals including: 1
administrator, 1 dentist affiliated with a university clinic, 6 physicians and 1 nurse midwife
(see table 3-1 below).
Main Findings. Based on the recruitment efforts required in the pilot, it may take
identifying four to six candidates to secure a single study participant. Recruiting eligible
providers who have not acquired an EHR system will be particularly challenging. Based on
feedback received during the pilot project, several providers were not inclined to undergo
the screening process, much less participate in the formal interview. Securing commitments
from health care providers to participate in a focus group will require a sustained effort from
the meeting organizer and will likely require repeated calls to each health care provider.
Access to the providers and their availability are two immediate challenges the organizer
can anticipate.
Patient care, office responsibilities, and related obligations consume most of a health care
provider’s available time. Since dates and times for focus group sessions will be
prearranged, it will be challenging to secure a pool of prospective participants whose
schedules easily align with the focus group meeting dates and times. For the pilot,
participants requested 3 to 4 weeks advance notice so they could clear their calendars of
potential conflicts for focus group meeting dates and times. Regardless of the effort,
inevitably conflicts will arise and some participant attrition will occur.
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Barriers to Meaningful Use of Electronic Health Records in Medicaid
Although alternates were not necessary for the pilot, it would be prudent to secure at least
two potential replacements for each anticipated session. Doing so will enhance the
probability that a full panel of focus group members will be available to participate.
Once commitments are secured from individual providers, routine reminders should be sent
via e-mail. The messages should be customized so that the provider is reminded or
informed about the project, its scope and purpose, and the general information that the
process is attempting to acquire. This will help the individual in preparing for the session
and will allow the meeting organizer to respond to any unanticipated conflicts or other
events that might impact the session. On average, pilot participants were provided at least
three notices prior to the scheduled interview.
Given the Medicaid orientation of the study, every opportunity should be taken during the
recruiting process to confirm with the provider the primary focus of the study. The
Screening Instrument should rearrange the location of several screening questions to better
verify eligibility the incentive program.
2.3
Recommendations for Main Study Recruitment Processes
Secure as much information about the respondent in advance of the call and then
validate that information with the provider. This technique may reduce the time
required to complete the Screening Instrument.
A thorough screening of potential participants must be conducted to ensure final
participants have a basic understanding of an EHR system, how it functions, and the
potential benefit/value that system can offer their practice. At the same time,
questions currently included in the Screening Instrument that are best reserved for
the focus group sessions should be reserved for the focus group meetings.
Follow-up messages to providers in advance of the study date are important. These
messages should mitigate the chance for scheduling oversight and can reinforce the
primary focus, orientation, and subject matter to be addressed in the study.
“Over subscribe” participants because attrition will occur. Having available/qualified
replacements will enhance the probability of having complete panels for the focus
group sessions. It would be prudent to secure at least two potential replacements for
each interview session that will be conducted.
2-4
3. EVALUATION OF FOCUS GROUP FORMAT AND CONTENT
3.1
Pilot Focus Group and Interview Methods
Participants in the pilot project replicated, as much as possible, the mix of eligible
professionals who would be represented in the main study. Participants included individuals
from various clinical areas and practice domains. The pilot project included both eligible
professionals with and without EHR experience. Private practitioners and Federally-qualified
health center (FQHC) employees were represented. Finally, the pilot project tested three
primary modes for conducting a focus group meeting: an in-person meeting, an informant
interview technique, and a virtual session.
3.2
Observations and Lessons Learned
3.2.1 Composition of Focus Groups
Main Findings. Clinicians, regardless of type, can be assigned to like groups with three
caveats: 1) A session dedicated exclusively to dentists should be arranged so that their
unique needs are clarified, 2) health care providers not experienced or familiar with an EHR
system should be interviewed separately from those who have experience; and 3)
administrators without clinical practice have little to contribute to the discussion about
particular EHR functions. The main consideration in convening focus groups is ensuring that
they are homogenous with respect to level of experience with EHRs. With only one
administrator in a group of clinicians, the administrator did not have much clinical
experiences with an EHR to provide.
The main study sets forth an explicit set of characteristics that will dictate the qualifications,
background, and experience of eligible providers recruited to participate in the interview
sessions. These characteristics include
Private practice clinicians and clinicians employed in an FQHC or rural health center
(RHC) setting
Clinical types/specialties, including family practitioners and/or internists with an adult
medicine orientation, physician assistants, nurse practitioners, certified nurse
midwives, pediatricians, and dentists.
Practice managers and/or clinic administrators
Providers experienced and inexperienced with the use of an EHR system
Providers who serve a significant number of Medicaid beneficiaries (i.e., 20%–30%
of the patient panel is made up of Medicaid beneficiaries)
A representative mix of providers practicing in urban, suburban, and rural settings.
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Barriers to Meaningful Use of Electronic Health Records in Medicaid
Using these selection criteria as a guide, the pilot project recruited nine eligible providers to
be interviewed. Table 3-1 provides a summary of the provider types and the type of
interview session to which each was assigned.
Table 3-1.
Composition of Pilot Focus Group Sessions
Group 1 – Informant
Interview (Individual)
▪
One private practice family
physician with no EHR
▪
One private practice
pediatrician with no EHR
Group 2 – Focus Group
Meeting
Group 3 – Virtual Focus
Group
▪
▪
One FQHC CEO (with EHR)
▪
One certified nurse midwife
from an FQHC (with EHR)
One FQHC family practitioner
(with EHR)
▪
▪
One private practice family
practice physician (with EHR)
One FQHC medical director
(with EHR)
▪
▪
One university-based dentist
(with EHR)
One private practice medical
director (with EHR)
NOTE: The pilot test group was limited to nine participants to comply with the Paperwork Reduction
Act.
3.2.2 Focus Group Mode, Setting, and Materials
Main Finding. In-person focus groups, in-person informant interview, and virtual focus
group techniques all yielded substantive results. If the virtual focus group technique can be
well managed by the meeting facilitator, it could enhance the opportunity to schedule more
events and should significantly ease scheduling conflicts. Rather than having participants
travel to a central meeting location, providers can participate in virtual sessions from their
offices.
In-person Focus Group. The in-person focus group was convened on Wednesday, January
12, 2011 at 3:10 p.m. EST and was concluded at approximately 4:45 p.m. Four participants
attended, including a certified nurse practitioner, clinic administrator, dentist, and adult
medicine family practitioner. The interview was conducted in a conference room located at
West Virginia Medical Institute’s (WVMI’s) Charleston, WV, office. The room was separated
from other office areas and helped to minimize any extraneous noise or related disruptions.
All participants arrived on site at the prescribed start time.
The conference room was well equipped for the interview. Paper and pens as well as copies
of all relevant resource materials were provided (Show Cards 1, 2, and 3). Flip charts and a
dry erase board were available to record presenter comments as applicable (Moderator’s
Guide, Questions I-A-3, and I-A-4). Light and room temperature were monitored to ensure
a comfortable work environment. No problems were noted. The room was equipped with a
recording device and microphone to capture all proceedings. Participants were advised in
advance of the interview that the session would be recorded and how the recording would
3-2
Section 3 — Evaluation of Focus Group Format and Content
be used (Moderator’s Guide, Ground Rules Section). A conference phone was also engaged
in advance of the interview to allow RTI project personnel to listen to the proceedings.
Neither recording the session nor having observers listening to the proceedings seemed to
interfere with or intimidate any of the participants.
In addition to the four participants, there were two project personnel on site, an interview
facilitator and resource person. Roles for both project personnel were explained in advance
of the interview.
One-on-one Informant Interviews. In addition to the in-person group session, two
individual interviews were conducted. These interviews took place with a pediatrician and an
adult medicine family practitioner. Neither of these physicians currently has an EHR system
and are only generally considering whether they will acquire a system for their respective
practices.
Given their limited experience with EHRs and the Medicaid Meaningful Use requirements,
neither provider was inclined to participate in a larger group session. Each, however, agreed
to be interviewed to test the Moderator’s Guide. Since the design of the study sought to
include the opinions and observations of eligible providers who do not have EHR experience,
the decision was made to proceed with individual interviews. Comments from these
providers were enlightening and will be used to assess any changes that may need to be
made in the Moderator’s Guide. These health care providers were in the midst of deciding
whether to adopt EHR systems in their practices. These individuals may have anticipated
that the process of participating in a focus group session may help clarify their own
considerations about what is important in an EHR system.
Based on this experience and the challenges encountered in the pilot study, either a virtual
session or one-on-one interviews with providers without EHR experience would be the
preferred interview technique. Providers of this type should be segregated from providers
with EHR experience.
Virtual Focus Group. The virtual (conference call) interview session was convened on
Wednesday, January 26, 2011 at 2:30 p.m. EST and was concluded at approximately 4:30
p.m. The call originated from WVMI’s Charleston, WV, office and included a pediatrician and
a family practitioner from Pennsylvania and a family practitioner from Delaware.
In advance of the call, all participants were provided specific written instruction via e-mail
on how to access the conference line. All participants were able to join the call at the
prescribed start time. In advance of the interview, participants were provided copies of all
relevant resource materials that would be referenced during the conference call. (Show
Cards 1, 2, and 3). Show cards 1 and 2 had been initially submitted. A third show card was
created to facilitate discussion related to Question II-A-11.
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Barriers to Meaningful Use of Electronic Health Records in Medicaid
The session commenced with introductory comments made by the session facilitator and
roles for project personnel (WVMI and RTI) were explained. Participants were advised that
the proceedings would be recorded and how the recording would be used. No objections or
reservations were noted.
Based on the outcomes of the session, no discernable differences were noted between the
virtual interview technique and the informant interview session previously conducted. The
meeting facilitator was able to track and differentiate speakers. The exchange among and
between providers flowed well. Individuals did not interrupt one another when speaking and
all were given fair and ample opportunity to respond. The meeting facilitator was very
conscientious about identifying each participant by name before directing a question or
soliciting a response. Participants sounded as if they were fully and actively engaged during
the interview. There were no indications that any participant was either distracted or bored
during the session. The exchange was very spontaneous. It should be noted that there were
only three providers participating in the virtual pilot interview. For the main study, it is
recommended that as many as nine, but preferably five, individuals could be included in any
one virtual group session. To manage the process with a group of nine participants, the
meeting facilitator would need to be extremely focused and alert to any dynamics that
might impede the participation/input from any group member.
This technique proved to be as effective as the informant (in-person) interview in
generating substantive and thoughtful responses from participants.
3.2.3 Moderator’s Guide
Ease of Use
For purposes of the pilot study, the Moderator’s Guide was designed as a “question bank,”
in which certain questions were more appropriate for nonadopters, some for clinicians with
EHR experience, and some for in-person focus groups, while other language was more
appropriate for virtual focus groups. We found that having the facilitator use the entire
question bank was somewhat cumbersome. Thus, to enhance the facilitator’s use of the
Moderator’s Guide, the document will be customized for the specific type of technique used
to conduct the interview and for the specific focus group composition. The Moderator’s
Guide will be organized so that a version is tailored for use in an in-person focus group
meeting and a second Guide for use in a virtual group session. A third version will be
prepared that can be used to focus the questioning directed at a group of providers that
does not have an EHR system in place.
3-4
Section 3 — Evaluation of Focus Group Format and Content
Customizing the Moderator’s Guide to meet the needs and conditions of the various focus
groups should streamline its use by the meeting facilitator and mitigate the chance for
posing an unintended or inappropriate question while conducting the interview.
Items That Generated Productive Discussion
A provider’s familiarity and experience with an EHR system appeared to be the more
significant factor impacting whether a productive and engaged dialogue occurred during the
focus group session. For example, the virtual group participants were more experienced
with an EHR system and its functionality than the in-person group. Consequently, the virtual
group was able to engage in a much more substantive and thorough discussion. Knowledge
of the Meaningful Use standards and conditions that would confirm compliance with the
standards also seemed to influence the substance of a provider’s response.
In the virtual pilot interview, all participants had at least 2 years experience with an EHR
system. Two of the three participants were responsible for the selection and deployment of
the EHR system in their respective practices. The third participant had used an EHR system
exclusively in his practice. In light of this experience, each participant was able to offer
detailed observations, opinions, and comments. Responses reflected both a clinical and
administrative perspective on the challenges, barriers and benefits that could be achieved
through the use of an EHR system. This group was also able to address how the
functionality of their respective EHR systems could support the practices’ abilities to meet
the Meaningful Use requirements and affect the quality of service rendered to their Medicaid
patients.
The characteristics of the providers who participated in the virtual pilot test interview
differed significantly from the providers who participated in the in-person group interview.
The in-person focus group included an FQHC-based certified nurse practitioner, an FQHC
executive director, a family practitioner, and a dentist. Each provider represented a practice
that had an EHR system. However, their experience with their respective systems was
somewhat less than the experience reflected by the virtual group, and the functionality
and/or applications used by their respective systems was also not as extensive as suggested
by members of the virtual group. These distinguishing characteristics were also influenced
by the fact that the dentist participating in the in-person interview used a very unique
“dental-oriented record,” and the agency executive director was only able to generally
address some of the clinical application-oriented questions posed during the interview.
Overall, it appears that a participant’s experience and use of an EHR system as well as
his/her familiarity with the Meaningful Use standards influenced the substance of the
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Barriers to Meaningful Use of Electronic Health Records in Medicaid
exchange between group participants. This was particularly evident in how participants
responded to the questions posed in Section II of the Moderator’s Guide. This background
and experience was also reflected in how elaborate the responses were to questions posed
in Section III, particularly those questions related to a State Medicaid incentive program
(Questions III-AB-4, a, b, c; III-AB-6; and III-AB-7 in the Moderator’s Guide).
Items That Did Not Generate Discussion
Even more than the construct and/or content of a Moderator’s Guide question, the
characteristics of the participants seemed to influence the amount of discussion that
occurred during an interview. The in-person group, which was not as familiar with EHRs or
the Meaningful Use guidelines as our virtual group, generated less discussion around specific
Meaningful Use topics. It was also clear that clinicians (physicians and the nurse midwife)
were more capable of answering questions about their systems than the administrator or
dentist who were interviewed. It should be noted that the dentist interviewed for the pilot
was very knowledgeable about the electronic record that was in place in his specific
practice, but uninformed about an electronic health record applicable for a medical practice.
Questions I-A-3; I-A-4; and I-A-5 all generated more substantive discussion among the
experienced provider group than the group with less experience with an EHR system.
Among the less experienced practitioners, questions about factors considered prior to
acquiring an EHR system (questions I-A-5 regarding transition to EHR use and I-A-6, use by
other clinicians in the office) did not generate much discussion. This was probably because
several of the providers interviewed arrived at the practice after the acquisition decision was
made. The questions did not seem germane to the overall purpose of the study.
Items That Needed Further Clarification
Based on responses received during the pilot study, some provider participants did not
appear familiar with the Meaningful Use requirements, their State’s Medicaid incentive
program, resources available to assist in the selection and use of an EHR system (i.e., REC),
or the capabilities that other health care providers had related to the exchange of health
information. Several of the clinical respondents were not sure of the percentage of Medicaid
beneficiaries reflected in their particular practice or clinic.
Given the need to keep providers focused on the Medicaid orientation of the study,
whenever applicable, the moderator’s questions should be referenced with the term
“Medicaid.” This cue should help maintain responses that are focused toward a Medicaid
application rather than allowing the provider to speak more generally.
3-6
Section 3 — Evaluation of Focus Group Format and Content
Overall Effectiveness of Moderator’s Guide to Answer Research Questions
The Moderator’s Guide, as drafted, represents an effective tool for facilitating a focused,
meaningful, and efficient exploration of barriers that eligible health care providers may
encounter in meeting criteria to receive Medicaid incentive payments. Information acquired
from the series of focus groups sessions will provide a rich reservoir of data from which
actionable recommendations can be submitted to Federal policy makers as they consider
changes and/or modifications in how providers might qualify for Medicaid incentive
payments.
Proposed changes are more process oriented than content oriented. These relate to matters
such as identifying and selecting eligible provider participants and the organization and
composition of individual focus groups. As mentioned previously, the “output” of the study
will be most dependent upon the comments, observations, and experiences of those being
interviewed. For this reason, every effort will be made to secure an informed and diverse
group of provider participants.
3.3
Recommendations for Main Study Focus Group Format and
Content
There did not appear to be a specific reason to differentiate or segregate urban,
suburban, or rural providers. Based on the observations from the focus group,
location of practice is not as differentiating a factor as one’s experience with an EHR
system. These characteristics may be important for practical reasons in forming inperson focus groups.
There did not appear to be a particular reason to differentiate groups by practice
setting (i.e. FQHC affiliation) from private practitioners. Experience or familiarity with
an EHR system was more of a distinguishing factor for clinicians.
The meeting facilitator will need to be focused and assertive in order to manage the
dynamics of groups composed of six or more participants. In the pilot study, groups
included four or three participants. The virtual group, made up of 3 providers,
required the full 2 hours to complete the study. Reformatting/tailoring the
Moderator’s Guide to align with the interview technique to be used will help focus the
questions posed during the session.
To have a robust conversation within a focus group, it will be important for the focus
groups to be homogenous with regard to the participants’ level of experience with
EHRs. Providers with EHR experience should not be included with providers who do
not have an EHR system or are not inclined to acquire a system. As a result of this
recommendation, the selection of focus group participants would change from the
current sampling plan, which is outlined in Table 3-2, to a revised configuration,
which is outlined in Table 3-3.
–
This configuration retains the number of approximate completed interviews, with
the same number of provider types, with the notable exception of administrators.
It allows for nonadopters to be interviewed in more convenient “virtual”
environment. To maintain some geographic diversity among EHR adopters, the
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Barriers to Meaningful Use of Electronic Health Records in Medicaid
in-person focus group interviews would be supplemented with smaller virtual
groups emphasizing rural clinicians. The virtual groups would have fewer
participants per session as they are more easily administered with a relatively
smaller number of voices on the line.
–
This also would result in 13 sessions as opposed to the current plan of nine.
Table 3-2.
Original Focus Group Configuration*
Private Practice
#1
#2
#3
#4
(w/
EHR)
(w/
EHR)
(no
EHR)
(rural,
w/EHR)
Pediatrician
2-3
2-3
2-3
2-3
Adult MDs
2-3
2-3
2-3
0
0
Mid-level
providers
(NPs,
CNMs)
(PA-FQHC
only)
2-3
Admin. Staff
Practitioner
Type
DDS
Totals
FQHC/RHC
#5
#6
#7
#8
#9
(w/
EHR)
(w/
EHR)
(no
EHR)
(rural,
w/EHR)
Total
0
2
2
2
2
16-20
2-3
0
2
2
2
2
16-20
0
0
7-9
2
2
2
2
15-17
2-3
2-3
2-3
0
2-3
2-3
2-3
2-3
16-24
0
0
0
0
0
2
2
2
2
8
6-9
6-9
6-9
6-9
7-9
10-11
10-11
10-11
10-11
71-89
*Groups 3, 4, 5, 8 and 9 were to have been virtual focus groups.
3-8
Section 3 — Evaluation of Focus Group Format and Content
Table 3-3.
Revised Focus Group Configuration
Adopters
Non-adopters
#1-4 In
Person
(4 separate
groups)
#5 Virtual
(1 group of
dentists
only)
#6-9 Virtual
(4 separate
groups, focus on
rural providers)
#10-13
Virtual
(4 separate
groups)
Total
Pediatricians
8-12
0
3-5
3-5
14-22
Adult MDs
8-12
0
3-5
3-5
14-22
2-4 (FQHC)
7-9
3-5
3-5
15-23
4-5
4-5
16-22
Practitioner
Type
DDS
Mid-level
providers
(NPs, CNMs)
(PA-FQHC
only)
Admin. Staff
Total
8-12
0
0
0
0
0
7-10 in each
group
7-9 in one
group
3-5 in each group
3-5 in each
group
59-89
3-9
Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Appendix A
Barriers to Meaningful Use in Medicaid
Draft focus group participant screener—November 5, 2010
DATE:_____/______/______
Hello, my name is _________ calling from (FG AGENCY). May I speak with (FILL IN THE
BLANK)?
IF NOT AVAILABLE: LEAVE A MESSAGE TO RETURN YOUR CALL.
IF ASKED TO EXPLAIN YOUR CALL, OR IF YOU CONTACT SELECTED PROVIDER:
Hello, my name is _________ calling from (FG AGENCY). May I speak with (FILL IN THE
BLANK).
We have been asked by the U.S. Department of Health and Human Services to conduct a
series of focus groups with a variety of health care professionals. The purpose of these focus
groups is to understand any barriers you face in meeting criteria to receive Medicaid incentive
payments for using electronic health record systems, or EHRs.
We are recruiting health care providers to participate in a single two-hour focus group. The
results will help inform Federal policy regarding incentive payments for the adoption and use of
EHR systems for providers who treat Medicaid patients. Your name was selected from among a
list of health care professionals in your state who treat Medicaid patients. Your participation is
entirely voluntary and will not have any effect on your eligibility for Medicaid payments of any
kind. Naturally, all your responses will be kept confidential to the extent permitted by law.
The focus group will be held [DATE] in [LOCATION/BY CONFERENCE CALL/BY
WEB CONFERENCE]. The focus groups may include physicians, nurse practitioners, certified
nurse midwives, and health center administrators in your area; or if you are a dentist, other
dentists. We will include only one person per practice in any focus group. You will receive $200
as a token of our appreciation.
IF SUBJECT SAYS S/HE DOES NOT USE EHR SYSTEMS: It is not essential that you
currently use EHR systems in your place of work. We’re also interested in hearing from nonusers.
1
Public reporting burden for this collection of information is estimated to average 12 minutes per response, the
estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork
Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.
2
I’d like to ask you a few questions to make sure we have a variety of health care professionals to
represent the providers in your area. This should take only about 5–10 minutes.
1.
May I ask a few questions to determine if I am speaking with the correct person?
□
□
□
2.
CONTINUE
SET CALL BACK TIME
THANK THEM FOR THEIR TIME AND NOTE
AS A REFUSAL GO TO GOODBYE
IF TALKING TO AN ADMINISTRATOR. SKIP TO QUESTION 4.
I need to verify what type of practice license you hold. Are you licensed as a:
□
□
□
□
□
□
□
□
□
3.
YES
NO
REFUSAL
Physician (GO TO 2a)
Dentist (GO TO 2b)
Nurse practitioner (GO TO 3)
Physician assistant (GO TO 3)
Certified nurse midwife (GO TO 3)
NO PRACTICE LICENSE-ADMINISTRATOR (GO TO 4)
OTHER (GO TO END 1)
DON’T KNOW (GO TO END 1)
NO ANSWER (GO TO END 1)
2a.
What is your medical specialty?
□
PEDIATRICS (GO TO 3)
□
FAMILY MEDICINE (GO TO 3)
□
INTERNAL MEDICINE (GO TO 3)
□
OBSTETRICS/GYNECOLOGY(GO TO 3)
□
OTHER SPECIALTY (GO TO END 1)
□
DON’T KNOW (GO TO END 1)
□
NO ANSWER (GO TO END 1)
2b.
What is your dental specialty?
□
GENERAL DENTISTRY (GO TO 3)
□
PEDIATRIC DENTISTRY (GO TO 3)
□
OTHER, please specify___________ (GO TO END 1).
Are you currently licensed to practice medicine (dentistry, nursing, midwifery) in the
state of (FILL IN THE BLANK)?
□
□
□
YES
NO
LICENSE IS TEMPORARILY SUSPENDED
3
□
□
□
LICENSURE IS PENDING
DON’T KNOW
NO ANSWER
o IF NOT YES, GO TO END 1
4.
In order to qualify for Medicaid incentive payments to adopt and use EHR systems, 30%
of your patient visits must be with Medicaid patients. Or, if you are a pediatrician at least
20% of your visits must be with Medicaid patients. If you work in a Community Health
Center or Rural Health Center those percentages could include Medicaid, or uninsured
patients.
Based on your patient mix, do you think you might qualify for this incentive program?
□
□
□
□
□
□
YES (GO TO QUESTION 5).
YES-HEALTH CARE PROFESSIONALS IN MY HEALTH
CENTER WILL QUALIFY FOR THIS INCENTIVE PROGRAM
(GO TO QUESTION 5)
NO (GO TO END 1)
UNSURE (GO TO 4a.)
DON’T KNOW (GO TO 4a).
NO ANSWER (GO TO END 1).
4a. Do you think the percentage of Medicaid patients you serve might increase in the next
1 to 3 years so that you might be eligible for this EHR incentive program in the future?
□ YES (GO TO QUESTION 5)
□ YES- HEALTH CARE PROFESSIONALS IN MY HEALTH
CENTER MIGHT QUALIFY IN THE FUTURE (GO TO
QUESTION 5)
□ NO (GO TO END 1)
□ DON’T KNOW (GO TO END 1)
□ NO ANSWER (GO TO END 1)
5.
We’re interested in talking with health care professionals who are in different phases of
adopting and using electronic health records (EHRs) in their out-patient practice. I am not
referring to computerized scheduling, billing, claims processing, or other types of
practice management systems. Rather, I am referring to electronic record systems used in
clinical care, for things like patient demographics, electronic prescriptions, recording
patient histories, and recording your care for your patients.
I’d like to read a short list of ways that might describe where your practice is. Please tell
me which best describes the use of EHRs in your practice.
4
□
□
□
You do not have plans to purchase an EHR system in the next 12
months. (GO TO INVITE 1 OR END 2)
You plan to purchase an EHR system sometime in the next 12
months. (GO TO INVITE 1 OR INVITE 2 OR END 2)
You now have an EHR system. (GO TO INVITE 1 OR INVITE
2 OR END 2)
***********End of Participant Screener—determine INVITE 1, INVITE 2 OR END 2
based on responses given and participants already recruited******
INVITE 1: We would like to invite you to participate in a group discussion via conference call
about the barriers you face in meeting criteria to receive Medicaid incentive payments for using
EHRs. This research is sponsored by Agency for Healthcare Research and Quality (AHRQ), an
agency within the U.S. Department of Health and Human Services. This group discussion is
strictly for research purposes. The discussions will be recorded so that we can accurately report
the contents of the discussion. No one other than the research staff will see or hear the tapes. It
will last about 2 hours. As a token of our appreciation, you will receive a gift of $200. [GO ON
TO QUESTION 6.]
INVITE 2: We would like to invite you to participate in an in-person group discussion about the
barriers you face in meeting criteria to receive Medicaid incentive payments for using EHRs.
This research is sponsored by Agency for Healthcare Research and Quality (AHRQ), an agency
within the U.S. Department of Health and Human Services. This group discussion is strictly for
research purposes. The discussions will be recorded (both audio and video) so that we can
accurately report the contents of the discussion. No one other than the research staff will see or
hear the tapes. It will last about 2 hours, and refreshments will be served. As a token of our
appreciation, you will receive a gift of $200. [GO ON TO QUESTION 6]
6. The discussion will be held on {DAY}, {DATE} at {TIME} in {LOCATION, OR BY
TELECONFERENCE/WEB CONFERENCE}. Would you be interested in participating?
□
□
□
□
YES (CONTINUE)
NO (THANK SUBJECT AND GO TO GOODBYE)
DON’T KNOW / MAYBE (GO TO END 2)
NO ANSWER (THANK SUBJECT AND GO TO GOODBYE)
IF THIS SUBJECT WILL BE RECRUITED FOR AN INTERVIEW OR FOCUS GROUP, ASK
ITEMS 7–17.
7. Great! Now in order for us to analyze the information we collect at the focus group, I’d like
to ask you a few more questions. These will help us describe your current familiarity with
EHR systems and know a little about your practice situation. This information will be needed
in our analysis. This should take 3-5 minutes. Can I get your verbal consent to ask you these
questions to help us analyze the information we collect in the focus group?
5
□
□
□
YES (CONTINUE)
NO (THANK THEM FOR THEIR TIME, GO TO GOODBYE)
CALL LATER
(SET A CALL BACK TIME)
SCREENER: IF SPEAKING WITH AN ADMINISTRATOR, SKIP TO QUESTION 13.
8. SCREENER: HOW DID PARTICIPANT RESPOND TO QUESTION 5?
□
YOU DO NOT HAVE PLANS TO PURCHASE AN EHR
SYSTEM IN THE NEXT 12 MONTHS (GO TO 13)
□
YOU PLAN TO PURCHASE AN EHR SYSTEM SOMETIME
IN THE NEXT 12 MONTHS (GO TO 13)
□
YOU NOW HAVE AN EHR SYSTEM (GO TO 9)
9.
I’m now going to read a short list to describe the extent to which the staffs at dental and
medical out-patient clinics are using EHR systems. Please tell me which best describes
the use of EHRs in your practice.
□
□
□
□
□
□
10.
Now, I will list some ways to describe the degree to which your patients’ clinical records
might be kept electronically. Please choose the one which best describes this use in your
practice. Remember, this does not refer to electronic systems for billing and
reimbursement; only clinical records.
□
□
□
□
□
11.
You recently purchased an EHR system, but are not yet using it.
In general, you use your EHR system on a regular basis.
You use your EHR all of the time and with all of your patient
encounters.
DON’T KNOW
NO ANSWER
REFUSE
All of your patient records are kept electronically,
Most of your patient records are kept electronically, or
Fewer than half of your patient records are kept electronically
DON’T KNOW
REFUSE
Next, I will read a list of specific functions EHRs often provide. Some health care
providers use these features more than others. Please tell me which ones you use on a
regular basis.
a) Do you record patient demographics?
6
□
□
□
□
YES
NO
DON’T KNOW
REFUSE
b) Do you record active patient medication lists?
□
YES
□
NO
□
DON’T KNOW
□
REFUSE
c) Do you transmit prescriptions electronically?
□
YES
□
NO
□
DON’T KNOW
□
REFUSE
d) Do you receive or send health information electronically?
□
YES
□
NO
□
DON’T KNOW
□
REFUSE
e) Have you enabled automatic warnings for drug interactions?
□
YES
□
NO
□
DON’T KNOW
□
REFUSE
f) Have you enabled decision support rules?
□
YES
□
NO
□
DON’T KNOW
□
REFUSE
g) Do you generate patient lists for quality improvement?
□
YES
□
NO
□
DON’T KNOW
□
REFUSE
h) Do you report clinical quality measures?
□
YES
□
NO
□
DON’T KNOW
□
REFUSE
7
12.
Considering all of the locations at which you may have practiced during your career, how
long have you personally been using EHRs to keep patient records in your outpatient
practice?
Is it:
□
□
□
□
□
□
Fewer than three months,
Three to twelve months,
One to three years, or
More than three years?
DON’T KNOW
REFUSE
13. Let me read some descriptions of the settings in which you have served patients during the
last three months. Please tell me which of these best describes the practice setting where you
serve most of your patients. There can be more than one.
□
□
□
□
□
□
□
□
□
A private or solo practice
A hospital outpatient clinic
A free standing clinic or surgi-center (not part of a hospital
outpatient department).
A community health center or federally qualified health center
A rural health center
Anywhere else? (IF YES, GO TO 13a.)
NONE OF THESE
DON’T KNOW
REFUSE
13a. Have you served patients at…
□
A community mental health center?
□
A clinic operated by your state or local government?
□
A family planning clinic (like a Planned Parenthood Clinic)?
□
A health maintenance organization or other pre-paid practice such
as Kaiser Permanente?
□
A faculty practice?
□
Any other locations I haven’t mentioned?
□
IF ANY OTHER, Please specify ______________
14. In total, how many (physicians/dentists) serve patients at your primary office location?
□
□
□
□
□
□
NONE
ONE (SOLO PRACTICE)
2–3
4–9
10 OR MORE
DON’T KNOW
8
□
REFUSE
15. Is your location where you serve most of your outpatient visits a single specialty or multispecialty practice?
□
□
□
□
SINGLE SPECIALTY
MULTI SPECIALTY
DON’T KNOW
REFUSE
16. Can you confirm the spelling of your first and last name for future communications?
ENTER NAME HERE:
_____________________________________
17.
Please give me a mailing address and telephone number where you can be reached so we
can send you a confirmation letter and some information regarding the group.
IF IN PERSON: This will include the address and directions to the focus group meeting.
IF VIRTUAL: This will include information that will allow you to dial into a secure
telephone conference line for this focus group session.
ADDRESS:
__________________________________________
__________________________________________
CITY:
__________________________________________
STATE:
________________________ ZIP:______________
PHONE:
EMAIL:
(______)_______-________
_______________________
Thank you. The discussion group will be held on {DAY}, {DATE}, at {TIME}, (at
{LOCATION}/ by teleconference/web-conference. We will send you a reminder notice and
directions/a phone number in the mail and by email.
9
END: Thank you for your time. We look forward to your participation in the focus group. If
you have any questions in the interim, please contact Sean Hogan at RTI international. He can be
reached at 800-334-8571 extension 2-5265.
END 1: I’m sorry but I must have been misinformed about your (SPECIALTY / NUMBER OF
MEDICAID PATIENTS). Thank you, but at this time, we are looking for focus group
participants with different characteristics than you. Thank you for talking with me. Good bye.
END 2: Right now we have received a positive response from health care professionals who are
similar to you in terms of specialty and the type of care they provide. So, we will probably need
to ask someone else, so that we have enough variation to inform our research. I would like to
keep your name on hand in case it turns out that we need someone with your background. Would
it be OK for us to call if it turns out that we have a vacancy down the road?
□
□
□
YES. (SAY: Thank you. We will call only if we find a vacancy for
someone with your background.)
NO
MAYBE
GOODBYE: Thank you. Good bye.
10
Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Appendix B
Barriers to Meaningful Use of Electronic Health Records in Medicaid
Focus Group Moderator’s Guide
November 5, 2010
Directions sent to participants in advance of virtual focus groups:
‐
Please locate a quiet place where you will not be interrupted, where you will have access
to a telephone and a computer with Internet access.
‐
Please sign into the web-portion of the meeting at least 10 minutes before our scheduled
start time.
‐
You will receive a packet of materials for use during the focus group session. Please have
them in front of you during the session.
Materials to be distributed to virtual focus group participants prior to the session:
‐
Consent form (to be returned in advance of the session)
‐
List of EHR functionalities required to demonstrate meaningful use for the Medicaid
EHR incentive program (Show cards 1 and 2)
Welcome, Team Introduction and Informed Consent (5-10 Minutes)
Welcome. Thank you very much for coming to this group discussion (agreeing to this interview
if personal interview). We’ll be talking about the use of electronic health records and the
Medicaid EHR Incentive Program. Your ideas and opinions are very important to us.
Public reporting burden for this collection of information is estimated to average 120 minutes per response, the
estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork
Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.
1
I’m Linda Dimitropoulos and I’ll be facilitating our discussion today. I’m from RTI
International, a private, non-profit research organization that conducts research related to health
care and health care delivery. I am being assisted this evening by Patricia MacTaggart (Trish)
of the George Washington University School of Public Health. She is a lead research scientist
there, and is a former Medicaid director. I am also being assisted by my colleague (NAME) from
the West Virginia Medical Institute. She/he is (FILL IN THE BLANK). Trish and (NAME
from WVMI) may ask follow up questions during our discussion, provide answers to technical
questions you have, or offer insights.
We are holding several of these groups with health care professionals around the country. We’re
doing this for the Agency for Healthcare Research and Quality, which is part of the U.S.
Department of Health and Human Services. They are working in collaboration with the Centers
for Medicare and Medicaid Services to address how best to understand any barriers you face in
meeting criteria to receive Medicaid incentive payments for using EHRs.
FOR IN-PERSON GROUPS: I will be passing out consent forms. Let’s take a minute to read
them and fill them out so I can collect them before we start. You will get two copies to sign. One
copy is for you to keep; it has phone numbers to call in case you have questions afterwards. Once
you have signed the one for me, please pass it down to me.
FOR VIRTUAL GROUPS: I have a copy of your signed consent form here. If you need to please
refer to the copy of the consent forms that you signed and were asked to keep. If you need a new
one, let me know.
FOR BOTH VIRTUAL AND IN-PERSON GROUPS: These inform you that your participation
is voluntary and that we will protect your privacy. This says you don’t have to answer a question
if you don’t want to. You can refuse to participate even after we get started. It says that this
group discussion will last about 2 hours and that at the end of the session I will give you $200 as
a token of our appreciation for your participation.
Any questions before we move on?
Group Objectives (5 Minutes)
Our goal today is to understand, from your perspective, any barriers you may face in meeting
criteria to receive Medicaid incentive payments for using electronic health records (EHRs) under
the new Medicaid EHR incentive program. This includes finding out about the challenges—if
any—in establishing yourself as eligible for Medicaid incentive payments for adopting,
implementing or upgrading an EHR. If you have an EHR, we’ll be asking about barriers you’re
facing in using your EHR in a way that satisfies the criteria for “meaningful use.” We’ll define
2
these terms for you as we go along. Your experiences and opinions will inform both research and
future Federal policy.
Here’s how I’d like to proceed: First I’ll layout a few ground rules that help make focus groups
work.
Next, I would like everyone in the focus group to introduce themselves by giving their first
names only. Then we’ll get into the heart of the discussion. I have a set of questions and
discussion topics that I will be guiding us through.
Here are some ground rules that will help us work together:
1. First of all, everyone should know there is no right or wrong answer. We want to know
your honest experiences, ideas and opinions. During this group some of you may bring
very different experiences and opinions to the table. That is exactly what we’re looking
for. We are here to learn from you, and we want to hear from everyone and learn what
each of you thinks.
1a. FOR VIRTUAL GROUPS: I hope you are already in a quiet place where you will
be undisturbed for the duration of this call. If not, please take this time to find a quiet
place now. Also, if you have not already done so, please take out the material sent to
you. We will use the visual aide in the course of the discussion. (If using a web-based
meeting format, confirm that everyone is logged in.)
2. As a courtesy to everyone, please put phones or pagers on vibrate. I know in your line of
work, emergencies sometimes crop up. You may excuse yourself if you need to respond
to an emergency.
a. FOR VIRTUAL GROUPS: When it’s not your turn to speak, please put your
phone on mute if you are able to. This will reduce background noise for everyone
who is listening.
3. Also, please respect each other’s privacy. To do this, I’m asking you to not repeat
anything you will hear from your colleagues here today.
4. When we write our report, we will report what was said, but not who said it.
5. Only RTI (and WVMI during pre-testing) will be able to link your identity with any of
your answers. Your identity and anything you say here will remain private. This means
that your names, addresses, and phone numbers will not be used in any of our reporting.
We will not mention your practice by name.
3
6. You may have noticed the recording devices in the room. (FOR VIRTUAL GROUPS:
“We are recording this conference call.”) We want to give you our full attention and not
have to take a lot of notes. We will refer to the recordings when writing our report to help
ensure accuracy. We will not share these tapes with AHRQ, but we will provide AHRQ
with transcripts of our tapes. So please use only your first names during our discussions.
We’ll redact information that would specifically identify you as a participant from our
transcripts.
7. Because we are recording, it is important that you try to speak one at a time. I may
occasionally interrupt when two or more people are talking at once. This is to be sure
everyone gets a chance to talk and that responses are accurately recorded. Sometimes I
may need to move the discussion along to make sure we cover everything, and I may ask
those people who have contributed a lot to the discussion to give others a chance to
speak.
8. FOR IN-PERSON GROUPS: Should you need to go to the restroom during the
discussion, please feel free to leave. However, we’d appreciate it if only one person
would be out of the room at any one time.
a. FOR VIRTUAL GROUPS: If you are temporarily called away from the phone,
please go ahead and take care of the situation. While you’re gone, please do not
put us on hold. Phone systems with music or recorded messages for waiting phone
calls will interrupt the conversation. If you need to leave for a moment, it would
be better to hang up and dial in again. However, we’d appreciate it if only one
person would be off the call at any one time, if possible.
9. FOR IN PERSON FOCUS GROUPS: Please feel free to get a snack or a drink.
10. If you do not understand a question that I ask, please let me know. I’ll try to re-phrase it,
or explain what we are trying to get at with the question.
11. Please don’t hold back from giving us your honest answers. If you have something
negative to say, that’s all right. Sometimes the negative things are the most helpful.
Remember, there is no right or wrong answers. We just want to hear what you have to
say.
4
Introductions (10 minutes)
FOR IN-PERSON GROUPS: To start things off, let’s go around the
room and introduce ourselves, so we can get to know each other a
little better. Please tell us your first name, and little about the type of
health care you provide.
FOR VIRTUAL FOCUS GROUPS: To start things off, let’s
introduce ourselves, so we can get to know each other a little better.
Please tell us your first name, and little about the type of health care
you provide. I’ll start with (MODERATOR: CHOOSE SOMEONE
and THEN CALL ON EACH PERSON TO IDENTIFY HIM/HER
SELF).
Section I—YOUR GENERAL EXPERIENCE WITH USING
OR ADOPTING ELECTRONIC HEALTH RECORDS (20–25
Minutes)
When we speak of Electronic Health Records, or EHRs, I am not
referring to computerized scheduling, billing, claims processing, or
other types of practice management. Rather, I am referring to
electronic record systems that take the place of paper patient records.
The EHR systems we’re talking about are for clinical care, for things
like patient demographics, electronic prescriptions, recording patient
histories, and recording your care for your patients.
Moderator: Especially on the
virtual interviews, you may
find it easier to call on
participants by name.
I-AB-1. How many of you have access to an electronic health record
at the location where you practice outpatient care most often?
For those who do not have an EHR:
I-B-1. Do you know anyone using an EHR now?
a.
b.
What have you heard about them?
Do you have any concerns, or worries about using them?
1.
What are they?
Moderator: For those who say
yes (Group A), follow
questions A-X. For those who
say no (Group B), follow
questions B-X. Questions that
refer to both groups will be
labeled as AB-X.
5
We’ll get into more of those in a little while.
I-B-2. Do you have any plans for buying an EHR system?
a. IF YES: What are the biggest reasons for you to
acquire an EHR?
b. IF NO: What are the biggest reasons for not getting an
EHR?
PROMPT: Are they too expensive? Would they cause
disruptions? Are you worried that it would take a long time
for your staff to get up to speed in using an EHR?
Moderator: For Question
I-A-2 and I-B-3, you may list
the following functions on a
dry erase board flip chart, or
show card to facilitate
discussion, or in virtual focus
groups, refer to slide on screen
(if web-based) or item in
material sent to participants in
advance.
•
•
•
•
•
•
•
•
•
Patient demographics
Medication lists
Medication orders
Problem lists
Medication allergy list
Sending prescriptions to
pharmacy
Checking for drug
interactions
Clinical decision support
Public health reporting
Moderator: After hearing
responses to Question I-A-2,
put a box around the items that
participants use frequently.
a.
What, if anything, might make you want to get an EHR?
For those of you who do have access to an EHR:
I-A-1. Some of you may practice in more than one location. If
so, do you use more than one EHR system?
a. Has switching between systems posed any particular
challenges to you? Please explain.
b. Are you able to use of all of the functions available in
all of the EHR systems you use?
I-A-2. FOR IN-PERSON GROUPS: Now, Trish MacTaggart
will put up a list of functions that EHR systems often have.
For those of you who have an EHR system, which of these
functions are you using on a regular basis? Are there others
that you’re using that we didn’t list?
FOR VIRTUAL GROUPS: Please pull out the visual aid from
the material we sent you called “Show card 1.” For those of
you who have an EHR system, which of these functions are
you using on a regular basis? Are there others that you’re
using that we didn’t list? As we go through the list, we’ll ask
you to put a box around those that we hear people using most
frequently.
6
I-B-3. Now, I’d like to talk about some specific EHR functions
that are available.
(Assuming these will all be virtual focus groups): Please pull
out the visual aid from the material we sent you called “Show
card 1.” Which of the functions would be most helpful to you, if
you were to use an EHR? Which are the most intimidating?
I-A-3. Now, please look at those functions that do not have a
box around them—the functions you say aren’t being used very
frequently. Why is it that you don’t use this so much?
a. Would you like to use any of these functions more
often?
b. IF YES: Why aren’t you using (NAME SOME
SPECIFIC FUNCTIONS) more often?
I-A-4. Now, for the functions that you are using, the ones that
are in the box - would you say you use these functions for all
patient records, most patient records, or fewer than half of your
patient records?
a. Why is it that you aren’t using these functions for all of
your patients?
PROMPT: Are they not relevant? Are they difficulty
to use, or find in your system?
Now I’m going to step back and ask you to think about how
you:
- FOR GROUP A: …selected an EHR and made your
transition to using EHRs in your primary practice
- FOR GROUP B: ….might select an EHR in the future
I-AB-2. What were (are) the characteristics of an EHR that
affect(ed) your selection of a particular EHR system?
Moderator: For Question I-AB-2,
probe for concerns about having an
EHR that meets the needs of special
populations (e.g. children, patients
with special needs.) Listen for
differences between provider types
(e.g., dentists, midwives,
pediatricians.)
7
Moderator: For Question IAB-3, you may prompt to see
if there are other provider
types, like behavioral health
providers, that participants
would like to share electronic
health information with for
better care coordination of
Medicaid patients.
I-A-5. Once you installed the EHR system you use in the
location where you see the most patients (we’ll call this
your primary practice), how long did it take for you to
feel comfortable using the system?
a. What was the transition period like?
PROMPT: Did you feel like you were wasting a lot of
time looking for ways to record something?
b. Did you feel uncertain that the system
would capture the information you needed
recorded?
c. Did your patient interactions change
during this period?
I-AB-3. Do you know whether other types of providers in
your area–like nursing homes, community mental health
centers, or emergency departments–are able to transmit or
accept electronic information?
a. In what ways does that affect your interest
in using an EHR?
b. How did that influence the timing of your
adoption?
c. IF THE OTHER PROVIDERS HAVE
NOT ADOPTED: Do you think you would use
your EHR more (or choose to adopt sooner) if
other providers in your area were using EHR
systems.
I-A-6. Are the other clinicians in your office (health
center) using the system more than you, less than you or
about the same as you?
8
I-A-7. Is there a management team at your practice (health center)
encouraging you to make use of the EHR system you have? If so, in
what ways?
I-A-8. Do you know whether your practice (health center) is using an
EHR that is certified, or is seeking certification in order to participate
in the incentive program?
Moderator: For Question IA-8, be prepared with a brief
description of certification and
the certification process.
‐
a. How important is having a certified EHR to the selection
decision at your practice?
Any difficulties in
upgrading to a certified
EHR product?
9
Moderator: Question II-A-9
is about the use of structured
data. It is intended to help
understand how much
difficulty is experienced by
clinicians in using some
structured data—since Stage 2
MU will require greater use of
structured data.
Stage 1 measures that require
structured data include:
a)
b)
c)
d)
e)
f)
demographic data
height
weight
blood pressure
diagnoses
medications and
medication allergies
g) lab test results
The standards for these data
items are SNOMED-CT
(Systematized Nomenclature
of Medicine Clinical Terms),
and LOINC (Logical
Observation Identifiers Names
and Codes).
Moderator: For Question IIA-11 you may write the items
a-g on a dry erase board or use
show card 2 if it helps
participants.
When asking about challenges
in using these functions, probes
to use:
‐ Differences between
provider types (if any).
‐ Why certain functions are
challenging to use.
Section II (applies to Group A only)—Specific Uses (10-20
minutes)
Let’s talk a little bit more about how you use the EHR system.
II-A-9. Most of the EHR systems want you to record some
information using structured data. This means data that is
standardized, and could be entered in drop-down boxes, buttons, and
check boxes. This may also mean that entering non-standard data
would result in an error message. You cannot easily change the
formatting, but this makes it easy to retrieve and compile
information.
a. How do you feel about using this structured data?
b. PROMPT: What do you like and dislike about structured
data?
c. PROMPT: Are there specific instances when having to use
structured data frustrates you? Does it make things easier for
you? Please explain.
II-A-10.
Does using structured data make it easier or more
difficult for you to enter orders, to code diagnoses, or to enter
prescriptions?
a. Do you find the word choices or units of measurement (i.e.
for a drug dosage, volume, weight) are appropriate for your
use?
b. Does anything about the use of structured data conflict with
what you learned in your medical or dental training?
II-A-11. Now I’m going to list some functions that a provider will
need to use frequently in order to qualify for the Medicaid EHR
incentive payment. For each one of them, please tell me if you
currently use this function in your EHR. I’m then going to ask you
about the challenges you face in using these functions.
10
Functions related to patient engagement:
a. Provide a clinical summary to patients after their visits.
b. Provide an electronic copy of patients’ health information
upon request.
c. Provide patients with access to their own health information
online.
d. Identify patient-specific education resources to provide to
patients.
e. Send reminders to patients for preventive and follow-up
care.
Moderator: For subparts a-e,
which reference patient access
to information, probe or listen
for any characteristics of the
Medicaid population that might
impede their participation in
patient/family engagement
activities.
Functions related to maintaining patient records:
f. Record race, ethnicity, and preferred language of your
patients in their medical record.
g. Record smoking status for patients 13 years of age or older.
Moderator: For subpart k
you may prompt with
“Transmitting prescriptions
electronically requires
pharmacies to be able to accept
them. Patients also need to be
able to identify the pharmacy
they want to go to.” Listen for
barriers that might be related to
Medicaid patient population
characteristics. For example,
they may be mobile and not
have the same pharmacy to fill
chronic disease medications. If
participants identify Medicaidspecific barriers, ask why they
think those barriers exist?
Functions related to clinical decision support
h. Implement a drug formulary check system, with access to at
least one drug formulary.
i. Create growth charts for children.
Functions related to electronic information exchange
j. Share information electronically in your area with
specialists, labs, pharmacies, nursing homes, or hospitals.
k. Electronic prescribing.
Other
l. Report clinical quality measures.
m. Generate list of patients by specific conditions for quality
improvement or other activities.
n. Perform medication reconciliation at times of transitions
between care settings.
o. Provide a summary care record for patients who transition
from your practice or are referred elsewhere.
Moderator: For subpart l,
listen for any concerns about
the relevance of clinical quality
measures for meaningful use to
the Medicaid provider
population.
11
Moderator: After getting
responses to question III-AB4, take questions about the
general features of the
Medicaid incentive program.
If some information is
necessary, post a list of facts
about the Medicaid EHR
incentive program. For virtual
focus groups, have slides
prepared or refer to materials
distributed in advance.
Moderator: For Question IIIAB-5, follow up with prompts
about whether participants had
any difficulty determining the
percentage of Medicaid patient
encounters or patients.
- For private practice
providers, any concerns
about tracking patients by
payer?
- For CHCs and RHCs, any
concerns about calculating
their proportion of “needy
individuals” vs.
Medicaid/CHIP?
- For both—is Medicaid
insurance status stable
enough over a 90 day
period to get a snapshot of
percentage patient
encounters attributable to
Medicaid?
Moderator: Before leaving
Section III, ask if there are any
providers that serve Medicaid
patients from more than one
State. If so, ask if they have
issues with selecting the State
from which to apply for the
incentive program, if not
already mentioned.
Section III—Effect of the incentive programs on EHR
selection/adoption/use (20 minutes)
Now, let’s talk about the Medicaid EHR Incentive Program
more specifically. Right now the state Medicaid program is
or will be offering monetary incentives for health care
providers to adopt and make use of certified EHR systems.
III-AB-4. Would you say that you are familiar with the
Medicaid EHR Incentive Program?
a. If so, where have you gotten information about the
program?
b. What is your understanding of how the program
works?
c. On what aspects of the program would you like
clarification?
III-AB-5. One of the requirements for receiving Federal
incentives is having a certain proportion of your patient
encounters with Medicaid patients. About what percent of
your patient encounters in the last three-month period were
Medicaid recipients?
a. Out of curiosity, how did you arrive at that number?
III-AB-6. How much does this program influence whether
you would adopt a certified EHR, upgrade to another EHR,
or use your EHR according to the meaningful use criteria?
a. Are there any of you who are affected other
providers in your practice, who might qualify for the
Medicare EHR Incentive Program but not the
Medicaid EHR Incentive Program? How so?
III-AB-7. Are these incentives enough to cause you to make
more use of EHR systems?
12
Section IV—Factors that may facilitate meaningful use (15
minutes)
I’d like to ask you about any help that you may have received (or
will receive) in adopting and using an EHR.
IV-AB-8. What organizations or entities, if any, have you turned
to for help in selecting your EHR (or will help you select) an
EHR?
IV-AB-9. Were there any that helped train you in using it? (For
non-adopters, do you anticipate anyone might be assisting you in
using an EHR you have adopted?) This may include vendors,
health center networks, hospital administrators, or others.
IV-AB-10. Regional Extension Centers—or RECs—are located
throughout the country to assist practices with fewer than nine
health care providers adopt and use EHRs.
a.
Are you familiar with the REC in your area?
b. What sort of support has your practice received from the
REC?
IV-AB-11. Are commercial payers offering incentives for
adoption or use of EHRs, or penalizing you for non-use of
EHRs?
a.
What are some of those incentives?
b. How much did policies of private insurers help you make
up your mind about adopting an EHR system?
c. Did private insurers not only influence whether you’d
buy, but did they influence which type of EHR to buy? How?
Moderator: On questions IVAB-8 and IV-AB-9, when
discussing these questions with
Community Health Centers or
Rural Health Centers, probe for
comments about the degree to
which Health Centered
Controlled Networks are
operating in their areas, and if
so, how useful they are in this
regard.
Moderator: On Question IVAB-10, if time allows, ask
“What is the REC not doing
that you think it should be
doing?”
Moderator: On Question IVAB-11, follow up with a probe,
“Are there any quality
initiatives that play a role in
your decision whether to
adopt/use EHRs?” Listen
specifically for any mention of
“medical home” or “patientcentered medical home.”
13
Moderator: On Question IVAB-13, ask about benefits of
using EHRs beyond EHR
Incentive payments.
Consider probing for these
factors (from AHRQ’s Will it
Work Here? Guide.):
‐
‐
‐
IV-AB-12. Do you know if your State or local public health
department has the ability to accept electronic health data for your
patients, for example, immunizations, or syndromic surveillance
information?
IV-AB-13. Is there anything I didn’t ask about that may influence
your decisions about the adoption and use of EHRs?
Awareness of peers who
have had success with
EHRs
Belief there is evidence
that EHRs improve quality.
Benefits to organization
(e.g., better working
conditions, enhanced
satisfaction)
14
Section V—Technical assistance (10 minutes)
V-AB-14. Have you been offered any assistance to help ensure that
you satisfy the meaningful use requirements and eligibility
requirements for the EHR incentive program? What type of
assistance do you most need?
Moderator: For Question VA-12 and V-B-4, probe for:
‐
Barriers specific to
Medicaid providers, and if
so, why
‐
Broadband connectivity
‐
Appropriateness of clinical
quality measures required
for demonstrating
meaningful use
‐
Any laws or regulations
that are in place that you
think conflict with the goal
of using an EHR systems
‐
Factors from AHRQ’s Will
it Work Here? Guide, such
as:
I can see we have time for one more question.
V-A-12. Are there any barriers to using specific functions within an
EHR system, which we may not have mentioned yet?
V-B-4. Are there any barriers to adopting, implementing,
upgrading an EHR system which we may not have mentioned yet?
o
o
o
o
o
o
Concern about
scope of change
Costs (financial
and otherwise)
Lack of leadership
Risks
Organizational
culture
Past failures
Moderator: Check with Trish
MacTaggart and WVMI for
any final questions and
clarifications they think
necessary.
15
Closing (5 minutes)
FOR BOTH VIRTUAL AND IN-PERSON GROUPS: Thank you very much for your time.
Your comments and insights will be very helpful.
FOR VIRTUAL GROUPS: You should receive a check in the mail in about 10 days. If you do
not, please contact me and I will look into any delays. Thank you again for your cooperation.
16
Barriers to Meaningful Use in Medicaid
Show Cards
Information to be displayed during focus groups. For in-person focus groups, this information
will be distributed in hard copy and posted on signs displayed on easels. For virtual focus
groups, the information will be distributed electronically or displayed on the web conferencing
interface.
Show Card 1
• Patient demographics
• Medication lists
• Medication orders
• Medication allergy list
• Problem lists
• E-prescribing
• Drug-drug interaction checks
• Clinical decision support
• Public health reporting
Show Card 2
Stage 1 measures that require structured data include:
• demographic data
• height
• weight
• blood pressure
• diagnoses
• medications and medication allergies
• lab test results
Show card 3
Functions
related to
patient
engagement
Functions
related to
maintain
patient records
Functions
related to
clinical
decision
support
Functions
related to
electronic
information
exchange
Provide a clinical
summary to
patients after
their visits
Record race,
ethnicity and
preferred
language of
your patients in
their medical
record
Implement a
drug formulary
check system,
with access to
at least one
drug formulary
Share
information
electronically in
our area with
specialists, labs,
pharmacies,
nursing homes
or hospitals
Provide an
electronic copy of
patients’ health
information upon
request
Provide patients
with access to
their own health
information on
line
Identify patientspecific
education
resources to
provide to
patients
Send reminders
to patients for
preventive and
follow-up care
Record
smoking status
for patients 13
yrs of age or
older
Create growth
charts for
children
Electronic
prescribing
Other
Report clinical
quality
measures
Generate list of
patients by
specific
conditions for
quality
improvement or
other activities
Perform
medication
reconciliation at
times of
transitions
between care
settings
Provide a
summary care
record for
patients who
transition from
your practice or
are referred
elsewhere
| File Type | application/pdf |
| Author | RTI_Doc |
| File Modified | 2011-03-17 |
| File Created | 2011-03-17 |