Form #3 Form #3 Moderator's Guide for Use with Virtual Focus Groups with

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 “virtual” use with EHR users

May 9, 2011

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 (if available) 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, 2 and 3)

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.

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 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.

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 I will send you $200 as a gift in appreciation of 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. The Medicaid Incentive Program has some specific rules about what practitioners need to do to qualify for this financial assistance. 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. 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 these terms for you as we go along. Your experiences and opinions will inform both research and future 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.

2. 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.)

3. I know in your line of work, emergencies sometimes crop up. You may excuse yourself if you need to respond to an emergency.

4. 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.

5. 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.

6. When we write our report, we will report what was said, but not who said it.

7. 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.

8. 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.

9. 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.

10. If you are 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 either use your mute button, or 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.

11. 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.

12. 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: You may find it easier to call on participants by name.

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 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 HIMSELF/HERSELF).

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?

1. Has switching between systems posed any particular challenges to you? Please explain.

2. Are you able to use of all of the functions available in all of the EHR systems you use?

I-A-2. Please pull out the visual aid from the material we sent you called “Show card 1.” As we go through the list, we’ll ask you to put a box around those that we hear people using most frequently.

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?

b. IF YES: Why aren’t you using (NAME SOME SPECIFIC 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, 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 ask participants to refer to 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:

1. demographic data

2. height

3. weight

4. blood pressure

5. diagnoses

6. medications and medication allergies

7. 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).

Section II—Specific uses (10-20 minutes)

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?

II-A-11. Now please pull out show card 3. I’m going to list some functions that a health care 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.

Moderator: For Question II-A-11 and Question II-A-12, ask 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:

a. Do you use your EHR to provide a clinical summary to patients after their visits?

b. Do you use your EHR to provide an electronic copy of patients’ health information upon request?

c. Do you use your EHR to provide patients with access to their own health information online, via a patient portal?

d. Do you use your EHR to identify patient-specific education resources to provide to patients?

e. Do you use your EHR to help send reminders to patients for preventive and follow-up care?

Functions related to maintaining patient records:

f. Do you use your EHR to record race, ethnicity, and preferred language of your patients in their medical record?

g. Do you use your EHR to record smoking status for patients 13 years of age or older?

Functions related to clinical decision support

h. Have you implemented a drug formulary check system, with access to at least one drug formulary?

i. Do you use your EHR to create growth charts for children?

Functions related to electronic information exchange

j. Do you use your EHR to share information electronically in your area with specialists, labs, pharmacies, nursing homes, or hospitals?

k. Do you use your EHR for electronic prescribing?

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.

Other

l. Do you use your EHR to generate reports of clinical quality measures?

m. Do you use your EHR to generate lists of patients by specific conditions for quality improvement or other activities?

n. Do you use your EHR to help perform medication reconciliation at times of transitions between care settings?

o. 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?

p. 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?

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, use prepared slides or refer to materials distributed in advance.

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?

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?

1. If so, where have you gotten information about the program?

2. What is your understanding of how the program works?

3. 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?

1. 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?

1. 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?

1. 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?”

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-7. What organizations or entities, if any, have you turned to for help in selecting your EHR an EHR?

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?

Moderator: 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)

IV-AB-10. Are commercial payers offering incentives for adoption or use of EHRs, or penalizing you for non-use of EHRs?

1. What are some of those incentives?

2. How much did policies of private insurers help you make up your mind about adopting an EHR system?

3. Did private insurers not only influence whether you’d buy, but did they 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?

a. Who gave you that help?

b. What type of help did you get?

c. 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

I can see we have time for one more question.

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.

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.

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