The CPTT meeting had good attendance this month. The entire session was dedicated to presentations from contract providers with the Exym EHR-S in production. Per Keely: Exym's product fits into the basic/low-end product category.
The following presenters were scheduled for today:
- Children’s Bureau of Southern California – Kirlos Guerguis / Exym
- Center for Integrated Family Health Services – Carol Koenig/ Exym
- Community Family Guidance Center – Leslie Watkins/ Exym(absent/cancelled)
Children’s Bureau of Southern California – Kirlos Guerguis
Introduction:
- Mental Health, Prevention, Foster Care agency
LA, San Bernadino, Riverside, and Orange Counties
Over 120 clinicians / over 1000 clients; 120 Exym users - Using Exym for 3.5 years now, ASP, with 3 redundant backup sites in 3 states
- Exym used for DMH only; not using for Foster etc.; looking at another system for Foster programs, although Exym is developing a Foster module
- Also using a 3rd party scanning system
Selection:
- Used a formal RFP process; looked at Clinivate, Anasazi, Infomedics, and Exym; Per Keely: they looked at the 2 lowest end products and one high-end (not familiar with Infomedics).
- Chose ASP solutions primarily for multiple backup sites and security reasons
- Process took 2 months, felt this was a long process
- Developed real scenarios for vendor demonstrations, developed by staff using worst case scenarios / workflows; 2 vendors, Infomedics and Clinivate backed out based on scenarios/needs. Per Keely: Three years ago the choices were limited in the low-end category and they only evaluated 1 product that met their needs, should always look to find at least 2-3.
Infrastructure:
- All staff has laptops, no one has desktops; transitioning to tablet PC’s as these allow both provider and client to sign on the tablet directly.
- Using trouble ticket reporting embedded in the product, to link to their in-house help desk system/staff to do the triage internally.
- No new staff were hired
- For community based workers, decided not to use remote EHR-S access or thumb drive solutions due to cost and reliability, but to use remote forms and download client data to laptops; when clinician has completed paperwork they go home and upload to the server. Recommend not allowing this be done at public wireless sites like Starbucks.
- Each laptop has LowJack and IT can remotely wipe out the data, provided clinician reports the missing laptop and the laptop connects to the Internet.
Per Keely: I will do a BLOG on the community based clinician/wireless solution options, as I think many people left thinking the laptop with wireless card solution is not feasible. Each agency must do their own geographic testing and determine the most productive and least risky approach. Wireless access is becoming a commodity and should be seriously considered rather than maintaining client data on portable devices for security reasons.
Contracting / Costs:
- They paid Exym a $8000 set-up fee which included 80% of the configuration work and some train-the-trainer time
- The license fees are $59 per user per month; Exym gave them a capped rate at 113 users for $80K per year user fees.
- Their annual project budget is $50K - $150K
- In your contract it should be clear who has access to your data and who owns the data. They required vendor to provide a name and non-disclosure for all staff with access to their data.
- “No retention” clause in contract, meaning if they choose to move to another server or vendor, the vendor provides a ‘dept. of defense’ level report validating that the data has been removed.
- Required that data can be provided in any format they may require or their new vendor may require. Per Keely: will be difficult to get a larger vendor to agree to an open ended format, will likely need to specify some standard format like ‘comma delimited’.
Implementation/Workflow:
- Implemented during slow season, November – January
- Completely paperless, did not replicate the DMH forms in data entry screens, but did replicate via reports.
- They scanned in two years of old paperwork initially.
- 100% PN’s are co-signed. Supervisor has 24 hours to un-approve the Note before it is locked.
- Using e-Tx planning libraries, wrote them themselves.
- Testing was done with a team of clinicians using real clients (with names disguised); this team continues to test all new versions
- Using Crystal reports, downloading to an Access database also to use reports they had before.
- Exym not handling Medicare yet
- Exym is doing Medi-Cal eligibility verification, however, Medi-Cal has recently put their certification process on hold and some agencies/vendors may not be able to proceed right away.
- Printing HCFA 1500’s for other payors, like Medicare
Training:
- Recommends building experts/power users from within the departments. Trained Power Users, including clinicians, Supervisors, and Billing staff. Keep in mind you need the power users to be good communicators.
- Laptops were good for training, had hands-on tools for each clinician without purchasing training equipment.
- Recommends web-based training, and web videos. They used Adobe Captivate to create online training tools using screen shots ($30) and make video (same tool that DMH IS used for their online training). Per Keely: All vendors prefer web-based training as it lowers their cost, however, I recommend on-site training for initial users. The Adobe product is one of many that would be good as an on-site training tool and then for ongoing training updates.
- Staff not inclined to use the manuals, they use the web video instead (called “Exym TV”)
- Rented a church in Pasadena for training; HINT: California Endowment / NPower will rent out their computer labs and some may do this for free.
- Conducted multiple trainings for all staff and also for site staff, required repeat trainings.
- Exym trained a couple of key staff and then the staff conducted the user training.
EDI:
- Going through certification now
- Kirlos was intimately involved in EDI implementation.
Audits:
- Are printing, signing and scanning in to Exym; then printing again for auditor, this has not been a problem (not originals).
- Has been through 3-4 audits, with 1-2% errors; County controller will not accept e-signatures for upcoming audit in March, in advance the auditors agreed to use the system, but on day they arrived they refused to use the computer and had to print everything out.
- Moving to tablet PCs which provider and client can sign on directly.
Lessons Learned:
- Culture change was difficult, paper versus computer; must engage line staff, all staff must buy-in.
- Train staff to use keyboard and PC/windows.
- Changed all business processes, A to Z
- Change is constant; vendor must be willing to support change constantly. This is critical for products that have little or no administrative tools to give the agency control of change management.
- For reward/recognition, gave out mouse pads and certificates with “Exceptional User”, was a big hit
- Team work, don’t depend on any one person
- System with ability to manage license expiration etc. is very helpful; would be great to automatically get the license change information from the board rather than the clinician, working on this.
Center for Integrated Family Health Services – Carol Koenig
Introduction:
- Carol has been with agency for 18 months; came from San Gabriel Children’s which has Exym also (agency had a falling out with another product vendor and transitioned in 2 months to Exym); looked at Clinivate, Anasazi, and Exym. They looked at the 2 lowest end products and one high-end.
- $2M in contracts: Baldwin Park school system contract, First 5, Chemical Dependency, Victims of Crime, and AB contracts
- 16 clinicians, school based and 16 non-school based
- Been with Exym for 1 year now, ASP model
Infrastructure:
- Hired Carol as new staff member, as database admin.
- Using desktops
Contracting / Costs:
- $4000 start-up fees, includes train-the-trainer and some user training;
- $59/month per user, Exym gave a flat rate after 25 users @ $1500/mo. + changes
Implementation/Workflow:
- Used SIFT data to migrate 18 months; did not enter any clinical data to start
- Launched in January 1, 2007; took about 2 months
- In EDI production since July 1st, 2007
- Now working on scanning and e-signatures
- Still keeping client signed paperwork in hardcopy
- Progress Notes are put into PDF’s and then onto CD’s, which are put into paper charts when client is closed/archived
- Downloading Exym MSAccess files monthly
- Cost report data elements can be provided to finance for the cost report, can provide it into an excel format for finance.
- Using all scheduling, including non-billable, in Exym with non-billable activity codes
- Using trouble ticket reporting embedded in the product
Training:
- Most staff are young interns
- Psychiatrist was most resistant, now a fan of Exym
- Used a college computer lab for training
- Used games etc. to make it fun
- Carol was trained first and then worked with Exym to train users
Lessons Learned:
- Was entering into IS from Green sheets, without checking Green sheets against the Exym system, this produced significant errors.
- Recommends flow charting all workflows.
- Clinicians can take on an additional client based on time savings
by Keely McGeehan, Sahara Management Solutions, Inc.
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