Attachment E -- Moderators Guide for Use with Virtual Focus Groups with EHR Non-Users_8-16-2011

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 non-users of EHR systems

August 16, 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 card 1)

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. 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. Even though you don’t have an EHR, we’ll be asking about some of the criteria for “meaningful use” to see if those features would be of value to you. We’ll define important 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.

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.

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 views of electronic health records, intentions to adopt (30–40 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-B-1. Do you have any plans for buying an EHR system in your primary practice location or other locations in which you practice?

a. IF YES: What are the biggest reasons for you to acquire an EHR?

PROMPT: Are there specific functions that are most attractive about using an EHR? Are there specific functions from which your practice would benefit most?

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? If you practice in more than one location, are you concerned with switching between a paper-based system in one location and an EHR in another location?

c. What, if anything, might make you want to get an EHR?

d. How has the management team influenced the decision to acquire an EHR or not? Please answer even if you are on the management team.

e. 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?

Moderator: For Question I-B-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

Moderator: For Question I-B-4, be prepared with a brief description of certification and the certification process.

I-B-2. Now, I’d like to talk about some specific EHR functions that are available. Please pull out the visual aid from the material we sent you called “Show card 1.”

a. Which of these functions would be most helpful to you, if you were to use an EHR?

b. Which are the most intimidating?

c. Have you heard of any challenges specific to using any of these functions?

d. What challenges, if any, to using specific functions have influenced your decision to acquire an EHR?

I-B-3. Do you know anyone using an EHR now?

a. What have you heard about EHRs from them?

b. What concerns or worries about using EHRs might you have based on what you’ve heard?

1. What are they?

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. IF THE OTHER PROVIDERS HAVE NOT ADOPTED: Do you think you would choose –or adopt sooner-- if other providers in your area were using EHR systems. Why (not)?

I-B-4. If you were to acquire an EHR, how important would it be to get an EHR that meets the certification criteria that would help qualify you for participation in the EHR incentive program?

Why?

Section II (applies to Group A only)—Specific uses (10-20 minutes).

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 slides prepared 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. What is your understanding of how the program works?

2. Where have you gotten most of your information about the program?

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. If you’re practice is considering buying an EHR system, how much does this program influence whether you would adopt a certified EHR, upgrade to another EHR, or use an 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 the incentives sufficient to cause you to consider adopting an EHR system?

III-AB-6. Do you serve Medicaid patients from more than one State? If so, how might you select 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. It is likely you’ve heard a lot about the issues related to using EHR systems, from many sources. Who would you turn to for help in deciding whether to adopt an EHR system?

a. For those individuals or organizations you identified, what makes them trusted sources for information?

b. Have you heard from anyone who already has adopted an EHR? Is their experience helpful to you in making decisions about the EHR adoption process?

c. If you were in the market, who would you trust to help you select your EHR (or will help you select)?

Now, let’s talk about implementation

IV-AB-8. Do you anticipate that anyone outside your practice might assist you in implementing an EHR? This may include vendors, health center networks, hospital administrators, or others.

IV-AB-9. Regional Extension Centers—or RECs—are located throughout the country to assist practices in adopting and using EHRs.

a. Are you familiar with the REC in your area?

b. Has anyone from a REC contacted your practice about adopting an EHR system?

IV-AB-10. 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?

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)

c. 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 your patients, 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?

I can see we have time for one more question.

V-B-4. Are there any barriers to adopting or implementing an EHR system which we may not have mentioned yet?

Moderator: For 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:

  • Concern about scope of change

  • Costs (financial & other)

  • Lack of leadership

  • Risks

  • Organizational culture

  • Past failures

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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