Form
Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Barriers to Meaningful Use of Electronic Health Records in Medicaid
Focus Group Moderator’s Guide
For in-person use with EHR Users
May 9, 2011
Welcome, Team Introduction and Informed Consent (5-10 Minutes)
Welcome. Thank you very much for coming to this group discussion. 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.
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.
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.
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 gift in 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. For example, the Medicaid incentive program has some specific rules about what practitioners need to do to qualify for the incentive payments. So our discussion is designed to help find out about the challenges you might face in establishing yourself as eligible for Medicaid incentive payments for adopting, implementing or upgrading 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 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:
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.
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.
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.
When we write our report, we will report what was said, but not who said it.
Only RTI 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.
You may have noticed the recording devices in the room. 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.
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.
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.
Please feel free to get a snack or a drink.
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.
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 answer. We just want to hear what you have to say.
Moderator:
For Question I-A-2, you may refer to show card 1 to
facilitate discussion.
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
Introductions (10 minutes)
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.
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.
I-A-1. Some of you may practice in more than one location. If so, do you use more than one EHR system?
Has switching between systems posed any particular challenges to you? Please explain.
Are you able to use of all of the functions available in all of the EHR systems you use?
I-A-2. Now, Trish MacTaggart will put up a list of functions that EHR systems often have.
a. Which of these functions are you using on a regular basis?
b. Are there others that you’re using that we didn’t list?
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?
c. Am I hearing somewhat different responses based on whether you are a dentist, pediatrician, physician, nurse practitioner, certified nurse midwife, or physician assistant? Why do you think that is?
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 difficult to use, or find in your system?
Now I’m going to step back and ask you to think about how you selected an EHR system and made your transition to using EHRs in your primary practice
I-A-5. What were (are) the characteristics of an EHR that affect(ed) your selection of a particular EHR system?
I-A-6. 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?
b. What barriers to using an EHR, if any, were most difficult to overcome during the first few months of using your EHR?
c. Did you run into any difficulty documenting clinical information in the EHR, or changes in patient interactions, or lack of confidence in using the system?
Moderator:
For Question I-AB-1, you may prompt to find out if there are
other provider types, such as behavioral health providers, that
participants would like to share electronic health information with
for better care coordination of Medicaid patients. Moderator:
For Question I-A-9, be prepared with a brief description of
certification and the certification process. Any
difficulties in upgrading to a certified EHR product?
I-AB-1. Do you know whether other types of health care
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 would have adopted sooner) if other providers in your area were using EHR systems?
I-A-7. Are the other clinicians in your office (health center) using the system more than you, less than you, or about the same as you?
I-A-8. Is there a management team at your practice or health center encouraging you to make use of the EHR system you have? If so, in what ways?
I-A-9. Do you know whether your practice or health center is using an EHR that is certified, or is seeking certification in order to participate in the incentive program?
a. How important is having a certified EHR to the selection decision at your practice?
b. If you are using a system that’s not currently certified, is the incentive program a factor in whether you upgrade or change to a certified system?
Moderator:
Question II-A-10 is about the use of structured data. You
may use show card 2 here. This question 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:
demographic
data height weight blood
pressure diagnoses medications
and medication allergies 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).
Let’s talk a little bit more about how you use the EHR system.
II-A-10. 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. What do you think about using this structured data?
PROMPT: What do you like and dislike about structured data?
b. Are there specific instances when having to use structured data frustrates you? Does it make things easier for you? Please explain.
PROMPT: Does using structured data make it easier or more difficult for you to enter orders, to code diagnoses, or to enter prescriptions?
c. Do you find the word choices or units of measurement (such as for a drug dosage, volume, weight) are appropriate for your use?
Moderator: For Question II-A-11 and Question II-A-12, you
may write the items on a dry erase board or use show card 3 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.
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.
If participants identify Medicaid-specific barriers, ask them why
they think those barriers exist?
II-A-12. Then I’m going to ask you about the challenges you face in using these functions.
Functions related to patient engagement:
Do you use your EHR to provide a clinical summary to patients after their visits?
Do you use your EHR to provide an electronic copy of patients’ health information upon request?
Do you use your EHR to provide patients with access to their own health information online, via a patient portal?
Do you use your EHR to identify patient-specific education resources to provide to patients?
Do you use your EHR to help send reminders to patients for preventive and follow-up care?
Functions related to maintaining patient records:
Do you use your EHR to record race, ethnicity, and preferred language of your patients in their medical record?
Do you use your EHR to record smoking status for patients 13 years of age or older?
Functions related to clinical decision support
Have you implemented a drug formulary check system, with access to at least one drug formulary?
Do you use your EHR to create growth charts for children?
Functions related to electronic information exchange
Do you use your EHR to share
information electronically in your area with specialists, labs,
pharmacies, nursing homes, or hospitals?
Do you use your EHR for electronic prescribing?
Other functions
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 Medicaid-specific barriers, ask why they think those
barriers exist?
Moderator:
For subpart l, listen for any concerns about the relevance
of clinical quality measures for meaningful use to the Medicaid
provider population.
Do you use your EHR to
generate lists of patients by specific conditions for quality
improvement or other activities?
Do you use your EHR to help
perform medication reconciliation at times of transitions between
care settings?
Do you use your EHR to create
reports on for the care received by patients with the same
condition? For example do you run reports on whether your patients
with diabetes have a Hemoglobin A1c test on record?
Do you use your EHR to produce a summary care record for patients who transition from your practice or are referred elsewhere?
II-A-13. Does your EHR allow you to produce reports on quality measures or on your patient panel characteristics?
a. What, if anything, is most challenging about getting data from your EHR for quality improvement, or practice management?
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 Programs are or will be offering monetary incentives for health care providers to adopt and make use of certified EHR systems.
III-AB-2. Would you say that you are familiar with the Medicaid EHR Incentive Program?
If so, where have you gotten information about the program?
Moderator: After getting responses to
question III-AB-2, 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.
Moderator: For Question III-AB-3, 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?
On what aspects of the program would you like clarification?
III-AB-3. One of the requirements for receiving 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?
Out of curiosity, how did you arrive at that number?
III-AB-4. 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?
Do you face any challenges because other providers in your practice might qualify for the Medicare EHR Incentive Program but not the Medicaid EHR Incentive Program? How so?
III-AB-5. Are these incentives enough to cause you to make more use of EHR systems?
III-AB-6. Do you serve Medicaid patients from more than one State?
If so, do you have issues with selecting the State from which to apply for the incentive program?
Section IV—Factors that may facilitate meaningful use (15 minutes)
Moderator:
For IV-AB-7 you may prompt with: For example, have you been
approached by large integrated health systems or academic medical
centers to do this? Moderator:
On questions IV-AB-7 and IV-AB-8, when discussing these
questions with CHCs or RHCs, 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 IV-AB-9, if time allows, ask “What is
the REC not doing that you think it should be doing?”
IV-AB-7. What organizations or entities, if any, have you turned to for help in selecting your EHR an EHR?
PROMPT: For example, have you been approached by large integrated health systems or academic medical centers to do this?
a. What are the characteristics of these organizations or entities that make them trusted sources for information?
b. Have you heard from any colleagues who were early adopters of EHRs? Did they help you understand how to optimize your use of EHRs?
IV-AB-8. Did anyone outside your practice help train you in using your EHR? This may include vendors, health center networks, hospital administrators, or others.
a. Has your EHR vendor been helpful in implementing and using your EHR?
b. Is your vendor an important source of information?
IV-AB-9. Regional Extension Centers—or RECs—are located throughout the country to help practices in adopting and using 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-10. Are commercial payers offering incentives for adoption or use of EHRs, or penalizing you for non-use of EHRs?
What are some of those incentives?
Moderator:
On Question IV-AB-10, 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 “patient-centered medical
home.” Moderator: Question IV-AB-12,
ask about benefits of using EHRs beyond EHR Incentive
payments. Consider probing for these
factors (from AHRQ’s Will it Work Here? Guide.): 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)
How much did policies of private insurers help you make up
your mind about adopting an EHR system?
Did private insurers not only influence whether you’d buy, but did they try to influence which type of EHR to buy? How?
IV-AB-11. Do you know if your State or local public health department has the ability to accept electronic health data, for example, immunizations, or syndromic surveillance information?
IV-AB-12. Is there anything I didn’t ask about that may influence your decisions about the adoption and use of EHRs?
Section V—Technical assistance (10 minutes)
V-AB-13. Have you been offered any help to ensure that you satisfy the meaningful use requirements and eligibility requirements for the EHR incentive program?
Who gave you that help?
What type of help did you get?
If you still need help, what type of assistance do you most need?
Moderator:
For Question V-A-14, 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: Concern
about scope of change Costs
(financial and otherwise) Lack of
leadership Risks Organizational
culture Past
failures
V-A-14. Are there any barriers to using specific functions within an EHR system, which we may not have mentioned yet?
Moderator: Check with Trish MacTaggart and WVMI for any final questions and clarifications they think necessary.
Closing (5 minutes)
Thank you very much for your time. Your comments and insights will be very helpful.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Barriers to Meaningful Use of Electronic Health Records in Medicaid |
| Author | Sean O. Hogan |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |