Using Cloud EMRs to Achieve Meaningful Use on a $0 Budget

Using Cloud EMRs to Achieve Meaningful Use on a $0 Budget

August 14, 2012 2:00 pm

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A free educational webinar on Using Cloud EMRs to Achieve Meaningful Use on a $0 Budget with Tom Gomez, Founder & Director of Transformations at the Edge and April Sage, Director of Healthcare Vertical and Marketing at Online Tech.

When: August 14, 2012 @ 2 P.M. ET
Where: Online.
Who: Tom Gomez, Founder & Director of Transformations at the Edge and April Sage, Director of Heatlhcare Vertical and Marketing at Online Tech.
What: Using Cloud EMRs to Achieve Meaningful Use on a $0 Budget
Description: A case study of EMR implementation in free clinics across the country – all accomplished without incentive funding. Reviews cloud computing EMR best practices, lessons learned, and perspectives from inside the industry.




View slides (PDF).

April: Let me re-welcome Tom Gomez, Founder and Executive Director of Transformations at the Edge, otherwise known as TATE. Tom has a fantastic story to share with you today of accomplishing meaningful youth in a free clinic environment on zero dollars of available budget. A feat I'm sure that many of us want to hear how you accomplished this. Tom is part innovator, part implementer, and part crusader. Tom, we’re looking forward to your story today. I’ll let you take it from here.

Tom: Great. I'm going to get started here. Hi, folks. I think we have a lot of people here, vendors, service providers, RECs and others. Let's get started here.

Let me quickly set the stage here for you and talk about Transmissions on the Edge, (TATE) just for a couple of minutes. About three years ago, when similar dollars were being put together and people were lying for it, I realized the need to actually address quite a few other audiences that have been left out from the conversation, from the engagement, to make things to user reality.I was running a program for the National Science Foundation Center here in South Florida at the Florida International University. I started to realize even more the need.

Anyway, fast forward, I formed my organization and put it together, to bring together collaboratives around the country, federated collaboratives as I report to them so that you can have ownership in your community. I just wanted to teach people how to fish and not fish for the day. Empower communities to come together and accomplish something around a common good. I found that particularly important or when you think about the disenfranchised population as in the people that are patients in free clinics around the country. I’ll explain to you what free clinics are here shortly.

Anyway, I've taken zero funding. I have no financial interest in any of the companies and solutions that I use. I live in the Cloud. I use Wikis. I use Fuse Meeting for a software-as-a-service for my online meetings, not GoToMeeting that is being used today, but that’s also good. Everything I do in a Cloud environment. It has brought efficiencies and scale to my activities in place that I hope you can learn from and use in your own environments.

April: Tom, can I ask a quick question here? I know it was a surprise to me and it maybe to those who are not in the middle of the industry, but can you just talk a little bit about the incentive funding and that it indeed does not apply to the Free Clinic environment? Is that correct?

Tom: Yes, I'm going to get to that in here in one second when I get to that Free Clinic slide. That was my next slide, April.

April: I'm jumping ahead. I’ll let you run with it.

Tom: Folks, you probably seen this line here. When I think of about health IT, this is what I think about. In fact about three months ago, I realized how Todd Park, CTO of HHS, and prior to that founder of Athena Health had been using the same line. That’s good to know that we’re talking the same language here. Anyway, I put this up because towards the end of it, we’ll talk about how we make this a little different.

Let me quickly tell you about health IT and free clinics and what free clinics are about and why they don’t qualify. Again, I hope you look at this as an use case and then you can look at why cloud-based solutions. Towards the end of it, you’ll start to recognize why Cloud based solutions have made this a reality that can be scaled.

Free clinics alone are not-for-profit organizations that provide care to the uninsured and underinsured in our country. There might be one in your community, you may or may not know about it. Most people are not aware of it.

I, myself was not aware of this three years ago until I met this wonderful lady down here by the name of Maricel Losa, who was a champion for free clinics in the state of Florida and is a founder of the Free Clinic Association. I was chatting with her about a few things as it related to some community activities from the National Science Foundation Center. She asked me at the end of the conversation, do you know anything about Free Clinics? The rest is history. I’ll tell you about what we’ve done with community stewards like the Maricel Losa down in South Florida.

There’s about 1,400 free clinics out there. The reason to April’s question, why they do not qualify is because they don’t charge anybody. They don’t charge CMN. When you show up at a free clinic, most of them are 100% to 200% below the poverty line. You clearly are the disenfranchised, the homeless, the people who lost their jobs. Most of these homes have sometimes two members that actually work. These are real people. They're in your community. They may be your neighbors. You just don’t know them. They go to these free clinics to get service.

Unfortunately, because of the incentive program was set up to accommodate for people that charge CMS, free clinics were left out of it. If health reform becomes a reality in all its form and shape, the administration would like to cover the population that goes to free clinics through the other programs including those at FQACs and CHCs, et cetera. Unfortunately, only about 40% or 50% of that population will be consumed by health reform. There would still be about 50% of this population, this disenfranchised population that will still need the free clinics.

For whatever the case, leaving out the stakeholder within your community, when we transform and we go to this IT transformation. It does not support the larger good. We created this program and I put it together and we’ll discuss how we went about doing it and how cloud services actually have a helped us do this better.

Any case, cost has always been the number one issue for free clinics in terms of getting a EHR. I'm going to give you a simple profile of the kind of people that come to me and ask me for help. It’s usually the Executive Director who’s being told there is no money to support your cause. If there was any money, you probably will waste it. And three, even if you did go through a good implementation, you probably won't maintain it.

This is the general profile of the clinic and an Executive Director who’s trying to help the needy in their community. When we finish the conversation the Executive Director says, “Yes, we’re going to get it done. We will get it done. We’ll be a center for excellence when we’re done with it.” We’re proving it everyday, with every clinic, that we can get it done. We can get it done on zero dollars, but we’re doing it for the right reasons. I’ll get into that here in just a second.

I will quickly and I put this up every time so that you can look in your communities and find about free clinics, support them with volunteer services, whatever it is. There are groups in your community and most of it is along the Eastern Seaboard. The reason you see the concentration here is it’s because this is a volunteer workforce. Whether there are more primary care physicians, there are more volunteers and the primary care physicians are along the seaboards. That’s why you see the concentration that’s shown on this chart here.

I’ll get back to why I think we’re successful with what we do. It’s not about technology. It’s about people. Now, we think about technology as a means to an end, not an end in itself. I reinforce that with our constituents with our free clinics. With our staff. It’s an inclusive process. We get everybody into it. I’ll explain that a bit further here.

April, am I going too fast, are we okay here?

April: No. It’s perfect, Tom.

Tom: Back in 2011 I was putting together this program and we set four objectives. Achieve “Meaningful Use, HIE, create a practice based research network, and advance the patients that are medical home. Now, most of you maybe familiar with the first two terms and the last term, but probably not familiar with practice based research networks, and I’ll explain that to you here shortly. But think about practice based research networks as a way to improve quality in clinics.

The reason we get this done is because people get behind the cost that goes beyond getting stimulus dollars back. Because we’re doing this in a way that improves the outcomes. We’ve set certain goals. We accomplished certain things. And by default, these clinics become meaningful users. You’ll see the simple ways in which we advance this.

Those of you who may not be familiar with patients that are in medical home, I hope everybody is familiar. It is the model of care embedded in health reform. Health IT is a big component of it. Without health IT, you cannot enable the patients in a medical home. If you want to look further into it, go to the NCQA’s website and look at PCMH and certification, etc.


Before I get to this process, I’ll have this light up here. I'm going to talk to you about why we use certain solutions and why we arrived at cloud-based solutions. Free clinics as I mentioned before do not have any funding available for each year of implementation. Most of them don’t. Some of them have gotten up to $100,000 in state funding through grants. I have two clinics here of which one could not afford the annual fees after the grant monies were spent. We ripped out and we went from two users in that clinic to 150 plus users in that clinic on zero dollars with the new solution we put in.

April: It’s amazing you’re getting such high level of adoption, very encouraging.

Tom: Again, it goes back to the benefits of cloud computing. Cost is a big issue. I was looking for solutions. I probably had played around north of 150 to 200 solutions over the years. I have been involved in mHealth since 2000. Tried everything from the business stocks to the opening MRs. Then about two years ago, I started to play around with the solution, which I'm using today. Again, this is not about promoting the particular vendor, it’s about advocating for solutions that work.

I stumbled upon a solution called Practice Fusion, which was free. I wasn’t so convinced that an ad supported model would work. I followed the solution. I had a test bed, played around with it. One day when we came back and looked at all the considerations including cost, usability, ease of access, subscription, you name it. There was a checklist of things that had to go. I realized, let's work with the solution called Practice Fusion and took it one clinic at a time. I’ll show you here shortly. It’s actually worked for us.

Setting aside the solution, let me talk about the process because I think where people failed to recognize is that you can put the best solution, that you have in the market in front of somebody, and still not get adoption. It’s particularly true when it comes to EHRs and clinical environments. Most people have a tendency to actually look at an implementation and start talking about how are we going to get the doctor engaged, how are we going to get the physicians engaged and how are we going to get the billing done, reporting done, et cetera.

You take a completely different approach to this. I start off at the front desk. I start off at that person that volunteers for three hours. We start off with people who have never test in the EHR before, but their input and the way in which they capture information from the time the patient who rings the phone at the office all plays a part in bringing together a good database of information, which then the physician and practitioners can look at and do their part. It’s as simple as it gets.

When we schedule using the solution we use for our free clinics and I'm not beholding the Practice Fusion. If somebody showed up and said, “I'm going to offer this cloud-based solution. You’ve got everything you need and by the way it’s free for you.” I’ll be all over it, but I've yet to see that party. We’re always looking for people to come in and join the party, but I'm going to keep talking about Practice Fusion because that solution we used and works. That simple thing called chief complaint gets put in when the phone is answered. It automatically feeds the SOAP note and I’ll show you that in a second.

Now you’ve just saved that two finger typing physician in key strokes. Measure your productivity gains by key strokes. Get people to do their part in the clinics and you will find the physician doing their part. There's peer pressure on the physician actually because you're surrounded by half a dozen people who know the utilities within the system and are using it well enough where the physician feels compelled to actually use the system.

This is why in the average clinic we have up to 50 users. Now by Practice Fusion standards, they're not considered active users because they don’t do 100 chart pulls a month. That’s because in a volunteer environment, you have ten times more people working there, pay for one tenth the amount of charge. There are hundreds of users in these clinics who are actually using the system and using it efficiently. The key here is training everyone in the clinic first, being inclusive in the process and giving the clinic ownership into success. Giving the clinic ownership in having responsibility for leading the project and the job gets done on its own.

There is a lot of work I do in training people. For example, I’ll quickly show you here how I use another cloud-based solution that most folks might know as a Wiki. I'm going to quickly share that screen. Bear with me.

April: Tom that looks like you're the mastermind of assembling a cloud of clouds.

Tom: As I always say, if it works, keep working on it.

This for example folks is a Wiki that I start off with which I had referenced here using Wiki based training. This is one for my current implementation. It’s a clinic up in Washington State, the volunteers in Madison Clinic. That’s John Melcher, nurse practitioner who sees just about 75% of the patient population. This is the staff, etc.

Let me quickly show you what's on here, very simple stuff. When we start educating people about the EHRs, I don’t tell them they have to implement. There’s a free solution but convincing them to use a free solution is another challenge because they have to really get comfortable that they can manage this. This Wiki actually includes about minimum six hours of training per units of training. This is actually carved back from a CME curriculum that I developed for a forty-hour course to physicians and others FMA or the AMA standards.

I brought it in here in a small dose for people to actually review. We start off right at the beginning setting up roles, responsibilities. We do a technology assessment. We do the scope of work and then we start teaching people how to use the system using simple videos, etc.

As you can see here, the one thing I like about the solution it can be accessed from anywhere. In a volunteer environment you sometimes have a minimum of 50 people volunteering in these clinics, not all of them come in at the same time. So coordinating meetings, trainings, etc. can be a hassle. Now, solution, problem solved.

The team is brought onto the Wiki. They have access to the Wiki. They can look at these training materials from anywhere. We track the activity of the individual users so we know we actually have given them X amount of training. Then, when they feel comfortable at that point in the clinic, the clinic supervisor or director sits down, plays a half an hour video, does Q and A, and the next thing you know, they are ready to be on. This is a simple example that most of you may have used the solution. If you have them, these videos from Practice Fusion, they’re actually both on YouTube, on their website and embedded within the EHR itself.

Video: There’s practitioner physician assistant level. During business hours, Monday thru Friday, 8:30 AM to 5:30 PM.

Tom: Fast forward here.

Video: To type, click on save and that will add that to your chart note list.

Tom: This is a full movie 30 minutes worth.

Video: Once you’re down there, you’ll come to the patient chart.

Tom: We’ll get to that in the EHR itself. I just wanted to show you these are the simple tools we use. Simple presentations, videos provided by Practice Fusion. We also have some other videos that I have on privacy and security, etc. These are videos that are in public domain, easy to use. These are videos that actually have presentations by Joy Pritts and others. I think this one here, it’s the Joy Pritts’ video. I think it’s found here but the information is out there.

The question is, or the challenge is, actually how do you bring them to your user in digestible chunks. Practice Fusion has about 150 videos available on YouTube, on their website embedded within the HER, but you have to break it down for them and set them on a track so that they can consume further after they’ve gotten that small amount of information and know their role within the environment that they’re going to be working in.

That’s what this Wiki does. It is a project management tool. It’s a learning management system. We collect information about their grants and grant deliverables. So we know right from the beginning what is the data capture that we need. Or what are the additional elements we can capture so that when these organizations, that rely on grants, have to present the deliverables or apply for new grants. What is the information they’re looking for? And do we have that information now for the use of the EHR?

If we do not have it in ways it can be consumed immediately, we have some other applications we’re developing to extract data and move it to the next level. But as you’ve noticed here hopefully is that we keep it simple. Implementing EHRs is not rocket science. So for me the technology part of it is out of way. People are using smart phones. People know how to use internet browsers, but the way in which you manage the projects is what really matters and using cloud solutions with its Wiki’s, EHRs, net meetings, whatever it is. It actually helps you do this in an efficient, collaborative way and in a way you can scale it.

Now people will say or let you know cloud-based solutions is all relative, whether or not it’s good for you or some other organization; that’s understood. Think about what you want, not about what you could have and then see if the solution fits the bill. If you look at it that way, and if you can get at least 85% of what you’re looking for go with it and implement it. It’s better than sitting around there and having another five vendors come and present to you and tell you about how their solution will work better. If you as a practitioner or somebody who’s been entrusted with the responsibility of RECs, the whole practitioner’s implementation, please take that approach and you’ll be pleased.

April: I love how you’re using these tried and true interfaces that people already understand how to use. That seems like it accomplishes a significant part of the initial barrier to adoption.

Tom: Exactly, people ask me, “Do you have the iPhone app?” “Do you have the iPad app?” and I say to them, “Yes, there is and there are more apps coming and Practice Fusion is going to.” But you know what? Physicians know what a keyboard is. Physicians know what a flat screen computer is. Don’t make life complicated. Let them get started using, just as you said, using the things they’re familiar with. Get a user and then they can see and look at what kind of modalities they now want to improve and they want a different form practice. Let them take that leap. But you’ve shown them how to use the system, the functionality, the utilities and how you can actually have good data capture using EHRs.

Let them take the iPads down the road, but I don’t recommend iPads or none of that stuff. I said, “Hey, there was iPad, that’s great guys, but when I write brands, I write it on iPad for every free clinic that participates. But I’m not going to make that one of the things that we put together when we implement EHR.”

Tom: Let me quickly go back here … here we are. So I’ll quickly run down this list. I’ll show you the interface within Practice Fusion for two minutes and then we’ll be fast forwarding here and taking Q&A.

My experience with clinics has been as follows. There’s about four people, maybe five that got 75% of patient life. They are your power users. Invest in your power users. Give them all of the time and effort that they ask for, you’d be surprised. I let people SMS me at 9:30 at night. I was on a call until 10:30 last night with my clinics in Washington. I have clinics in Florida still calling me at nine o’clock at night, but this is only implementations. What you will find out is if you would give them the time and effort at the beginning to your power users, they become the in-house trainers.

I have physicians - this is a fact - we have a clinic here in Miami in Little Havana called John Bosco Clinic. Over 110 plus physicians and medical students from the University of Miami’s Medical School go there every Tuesday on a rotating six week schedule. I spent some time and effort and trained the associate dean and four medical students, who are the leads in the project, and I spend maybe one weekend, half a weekend.

Today, we have for example at least one new position who will get access to the EHR at 4:30 or so for the first time. By 8:30 tonight, they will have signed a dozen plus SOAP notes and entered in the work. Now one might ask, “How the hell do you do it?” First of all, these physicians already use technology. They have an APEC implementation at University of Miami going on. They know how to use technology. What they are, are people who are trying to find out how to use certain features and functions. A dozen plus medical students who are all now trained just standing around him or her. They’ve used the system. They’ve been trained to use the system. They’re making the entries and the physician now is reviewing and then signing into record. In doing that 10 to 15 times, right there in the real world, before you know it, they know how to use the system. So training physicians is not difficult. It’s setting up the environment in which they start to use your solution that matters.

The cloud-based solution made that a reality because they were able to document it. They were able to retrieve records. They were able to speak with physicians and specialists at Jackson that’s affiliated with University of Miami and get that patient going. These are true stories. This happen every day and it happens because you have systems that are easy to use and access the information.

Quickly, I promise you. I don’t want to get into too much of these details but think about the early wins as you implement these. I think about most clinics that start off with the following and within two weeks after on day one, when they sign up, we either have a bulk upload of somewhere around 2,000 patients from Excel spreadsheets, which has been prepped while they were training. All the demographics are in. We spend two weeks sanitizing those records and before you know it, we have the best set of demographic data the clinic has had in a long time. In fact, for that matter best of the demographic data on an average, anywhere around the country. We also record a couple of things. We record smoking status and the nurses they can actually look at allergies, etc.

When you think about meaningful use and you look at that checklist. I don’t know, most of you might be looking at that checklist, let’s just go through it. You have drug-to-drug allergies, you have maintain problem list, maintain medication list, maintain allergy list, record demographics, record vital signs, record smoking status, clinical quality measures, etc, etc.

Without actually even knowing what we need to use criteria’s about. We’ve got plans implementing EHRs and meeting this criteria because they’re doing it for the right reasons. Then at the end of it, which is what I’m going to show you in the Practice Fusion interface, one of the things I liked about this service – this is all the test bench and none of these records are actually real patient records, all test records.

April: Glad to see we’re HIPAA compliance, Tom.

Tom: Yes, so here it is, Meaningful Use Dashboard. I’ve spoken to REC directors and others who are struggling with how to help people attest for Meaningful Use because they now have to take data out from the EHR, the Excel spreadsheets and all and … a real disaster. Here it is, this is a test bench. So I only meet eight measures out of 12. But what will we do actually to make them into Meaningful Users, to be at par with the Joneses, even though they’re not getting $44,000. A couples of months into this implementation as people are being on ramp. There is no such thing as half-baked or half-right. It’s 100%. The executive director has almost has taken oath and said, “No physician, volunteer, doesn’t matter who it is, they will use the EHR, so no exceptions.”

Once that’s done, what happens here is they constantly review this by provider and look to see how we’re doing. A simple example I’ll give you is if you look here, it says smoking status. I show zero and I collected zero for a reason. Most people do record the smoking status. It’s just they haven’t put it in, in structured form or they were not aware, not all of them are aware of the ability to in fact put in smoking status. It’s three clicks in the system we use. So for example I can go in here into lifestyle and going here and say new and you will then click cigarettes, done. Meaningful Use criteria, one was just met with two clicks.

This is the culture we developed within our free clinics. They don’t know anything about Meaningful Use criteria, but they do know recording smoking status is important. We’ve got clinics that just got $2,000 a piece for putting in smoking cessation programs. We’re now taking this information. We have a structured template in here for smoking cessation, and we are directing them for example, the state of Florida, the AHEC (Area Health Education Centers) actually get the tobacco cessation money from the big tobacco lawsuit. They want people to participate and so the free clinics now refer them to these AHECs, in which what I’m trying to do in other communities now that we’d expand. They now get actually money back to the free clinics for doing those referrals. Clinics may not get the $44,000 but we’re setting the stage for them to get paid for the right reasons. This is simple example of how you meet Meaningful Use, the early wins as I call it all about three clicks.

I also like the fact that Practice Fusion, as a partner, has been very good and we don’t have ads in our EHRs though, that’s the deal with Practice Fusion. They’ve been very generous for the support of nonprofits and remove the ads for them. They have this little - and for those of you who are watching who are vendors or others, this to me is probably the best, if not one of the five best pieces of paper on Meaningful Use.

This is a simple one pager that actually runs people through, watch a small video, learn more and go through it. I wish the ONC would put out something like this. It doesn’t have to be feature-specific as with the EHR but to really simply explain this. This is a one pager. Clinic directors, nurse practitioners, and the leads within this clinic, they have this on their wall. They have this on their desktop so when we sit down and we do these reviews and show them what needs to be actually looked at and how they can actually improve, we quickly go to that quick cheat sheet, play the video, two minutes, three minutes, whatever, boom, done. The next time we look at this dashboard, numbers start to improve. So we’re achieving Meaningful Use but doing it the right way and we have the utility built in here to be able to see it. Again, because it’s a cloud service, I can review these things, I can review this in every location for every provider, and provide feedback and here they are using the system without pressure.

April: Tom, how long does it usually take these free clinics to adapt to the new workflow?

Tom: You’d be surprised. I’m doing implementations in 90 days.

April: Wow.

Tom: Not six months, 90 days but I do spend a month prior getting people wanting to do it. It’s almost like you get them to a frenzy. Yes, we want to do it. We want to make this happen and next thing you know, they’re doing it. They’ve made a commitment and they’re doing it. Let me address the challenges and perhaps this might actually help answer some of those questions from a clinic director perspective. They’ve used solutions but some of them really didn’t know what the difference between a client service system and cloud-based solution. They don’t really understand any of it. These are the challenges we face in free clinics and it’s probably the same kind of challenges you face in other clinics. Now, data migration is always a big issue and I’ll get to that, loss of productivity, wrongful use, etc.

There was a question actually, and Todd if you’re listening in, this was your question. How do you get the staff to engage? It’s not difficult. What is difficult to do is to have consistency in the way in which providers and volunteers use the system. So it’s extremely important that you keep people focused on just following these best practices. While I’m all for physicians using their own custom templates in the free clinic environment, we build templates and we say, “That’s it, please try to use what we have.” So that no matter which volunteer cycles through there, the information is captured in a standardized way. These are the simple things that we do to actually get maximum productivity out of the systems that we use.

Data migration is a challenge, but sometimes there’s up to 200 pieces of paper that have to be scanned in but we have that activity running on parallel tracks. Sometimes we do volunteer weekends, where people come in, scanners and all, and help get these documents scanned and brought into the system. And as each clinic implementation goes by, we’re getting a little bit more efficient with this. But the reality is you don’t need to take all 200 pieces of paper that are in there. So what we do is we have the physicians look at the chart and say, “Now doc tell us what really do you want from this, we’ll still have the paper records, but let’s not waste three hours scanning 200 pages.” The doctor will say, “Well, give me the last two SOAP notes, give me the …” as long as the system has all the structured information, allergies, meds, etc. Just give me the last two SOAP notes, give me the last year’s labs, give me the three labs, that’s all we need.

As soon that’s been done, the staff will go scan just that piece of paper and bring it into the system. If it’s all the administrative paperwork, same thing. We know we have to have the eligibility verification, there is sovereign immunity type paperwork, for example the state of Florida. We need that for our physicians because they have sovereign immunity and the state statutes. Those are the kinds of things we get scanned. We’re getting better and better with data migration and we’re letting the clinic itself decide how much of the information needs to be digitized as opposed to just saying let’s just bulk upload everything. Now I’ve tried those routines and it’s a lot of fun to do it, when you’re doing volunteer weekends, but at the end of the day, it doesn’t really bear too much fruit.

Tom: Having said that, let me fast forward to the Practice-Based Research Networks and talk about Practice-Based Research Networks because this is where we are bringing continuity and persistence to the work we have done with implementing EHRs. Recently a good friend, Bob Rowley, and you may have read his post through HITECH Answers or my LinkedIn Group. Bob wrote about meaningful use. Meaningful use is to continue being meaningful users when the attestation period is no longer 90 days, but it’s actually 12 months. So you need to have some form of stewardship and some form of collaborative environment where a learning community where people continue to hold onto those best practices.

I have found that the Practice-Based Research Network is the best way to do it. So, Practice-Based Research Networks is communities of clinics, clinicians and physicians have come together and with the goal of practice improvement. If you keep the focus on practice improvement, everything else falls in place because you know what you’re trying to achieve with it. As much as it says its research, it’s really quality information. It’s research to the professor at the medical school in Colorado, but its quality improvement to the executive director and the physician in the clinic.

Now of course they’ve been around for 30 plus years. The concept came here from England’s agency AHRQ, Agency for HealthCare Quality and Research. It’s one of the biggest funders of PBRN activity. There’s 130 PBRNs around the country. The largest of them is the American Academy of Family Physicians National Research Network, which is lead by Dr. Wilson Pace, agood friend and collaborator. I consider him one of the cofounders of the Free Clinic Research and Engagement Network.

So what I’ve done is in order to continue maintaining the best practices for FREENet, which is the Free Clinic Research and Educational Engagement Network, we are now applying for grants as a collaborative. We just applied for the Patient-Centered Outcomes Research Institute grants with 40 some clinics that will be participating if we are successful. It’s a focus on health disparities. And what are we using? We’re using clinical body measures. We’re using all the things that we captured on our EHR as the basis for conducting our studies.

An opportunity like this, it was elusive to the free clinic in the past. They had to look for the Blue Cross Blue Shield Foundation in Florida or North Carolina and get the $50,000 grant here or there. They could never participate in our grants. They can never participate in NIH grants. Now with an EHR infrastructure in place and with good stewardship I brought together with the AAFP's National Research Network, Wilson Pace, DARTNet Institute, the University of Miami, etc. We now have the ability to bring an application to the NIH’s of the world that put out these funding opportunities that is credible enough because we have that data capture coming from EHRs.

What do we do? We take it one step further so meaningful use is all going to be about what happens after stage in stage three. We’re already trying to do this year by actually pulling data and pulling it together for quality improvement, extracting the data for research performance reports, etc.

This is why we separate ourselves from the fact in terms of using solutions that are not just looking at in terms of having programs but looking past incentive dollars. I want to make a point here… that we have to do this with five different vendors and client service systems, the amount of interface engines we would have had to build would just would not work. It is the fact that we have cloud solutions that is making this job that much easier to move forward from just data capture to actionable intelligence. It is very difficult to do that if you were trying to work with client systems who are all over the place.

This is the last slide and then we can go to Q&A after that. We’ve done 15 implementations so far. Here are the states. It’s underway. We’re going to scale rapidly towards the end of the year. We’re looking at 120 clinics with EHRs and the number will probably be somewhere around 6,000 users and I think we’ll beat these targets very fast. In the beginning when I said only about 10% having EHRs, that’s approximately 120 clinics. We hope with this program and the way it’s scaling that we will double the number of free clinics in the country that have electronic health workers.

April: Amazing accomplishment Tom, I really appreciate you sharing.

Tom: I’ll say this one thing, the success here is because the clinics want to make it happen. Tom Gomez is a good water boy.

April: Maybe a little more than that Tom.

Tom: The clinics make it happen. I will take that badge as good water boy any day, but the clinics make it happen and they’re doing it for the right reasons and I couldn’t be more proud.

April: Wonderful story Tom, thanks so much. One of the things that we hear about the cloud across the various industries and especially in the healthcare industry is that the cloud really is a leveler in the field. It enabled entities at all levels to participate at a functional level that really adds value, measures outcomes, improves outcomes, and that you have managed to assemble these various cloud technologies into something that people are actually using is a wonderful tribute.

Tom: It is.

April: Tom, is there any downside, if there is any downside to using cloud. What might that be? Are there any real stumbling blocks that you’ve encountered.

Tom: Yes, you could always put up the up the pros and cons. You lose connectivity, what are you going to do? You need to have some plans in place.

But the reality is you can have downtime with that client service system too. In fact, I guarantee you, you’re going to have more downtime with that client service system sitting in the back of your office and more maintenance calls than you will with a cloud service that you’ll access over the browser. You may have an outage with the internet service provider that’s it because you had a hurricane or this or that. But now how many outages do we really experience in a given year?

I always put it in perspective and say yes there is some risk in terms of not being able to access this but we have contingencies. One of the things we do which we didn’t discuss here is that we have some templates on how the clinic should function if we had no access to the net. and then we would get all of that information into the system and work with it. But that’s the first thing that I see as difficult. Now having all your information in somebody else’s cloud, of course you’re going to say, “Well, how about my data ownership,” right?

April: Uh-huh.

Tom: Cloud-based services like Practice Fusion do have rights to de-identify data, but on the HIPAA your clinic’s data is yours and they’re going to provide API, etc. to be able to extract that data and have that data locally. What I’m doing here now is to really build that interface engine so that we can take certain key data to do additional recording with this intelligence, etc. and bringing it into platform. So I’m taking my back up for the cloud is another cloud.

April: Common practice as we’re finding.

Tom: Exactly, so you’re now spreading your risk…reducing your risk because you now have two very good organizations that have your data, your primary provider, the EHR provider and it doesn’t have to be on, it could be anywhere. I just happen to use it because through the Salesforce Foundation, I’m able to procure nonprofits, enterprise seats up to 10 free seats. So I like the platform, but that doesn’t mean that’s the only platform we want to work on. If there were a couple of real good coders on my crew, I’d put them on something else, it’s simple as that.

Again, we want to think about this as when you do these back-ups and all that other stuff and you bring them into other clouds, be very sensitive to their experience with the present cloud, the primary cloud. You have a very friendly solution, you get used to it and then you say, “In order to back it up, we’ll put you into a much more complicated environment where we build the apps.” I’m being very sensitive to that in terms of how I transition them from their primary cloud or in actually beginning to use the secondary back-up cloud.

So that’s one concern that always comes up. But the primary concern that always come up is about data ownership. Are you going to be hostage? But I think Meaningful Use sets the stage for interoperable records. Eventually all data will move around so if the risk we’re taking probably, if any, is in the next five years.

April: Uh-huh.

Tom: When you’re collecting good information, five years go by pretty fast.

April: Yes, they do, don’t they? Tom, thanks so much. I really appreciate you sharing your perspectives and your story with us. We will be sharing a link to these slides and a recording of this webinar over the next couple of days with everyone who has attended today.

April: I quickly want to invite you to join us for our upcoming events next week Tuesday at two. Please join us for Implications of Recent Medicare Announcements on the Trends in Physician Payment Methods. That will be with Ralph Levy, attorney with Dickinson Wright and mark your calendars for Friday, September 14th and join us for a Fall into IT event. We will be hearing from Kirk Larson, CIO of Children’s Hospital, about his implementation of a Bring Your Own Device environment. We’ll be hearing from Dr. Dumanian, Chief of Plastic Surgery at Northwestern Memorial Hospital about his HipaaCat mobile app that he’s using to improve communication between the resident medical students and care providers.

Tom thanks so much for your time today, it was a pleasure having you. We love hearing your story and if you have some contact info to share for anyone who has follow up questions for you?

Tom: Yes, Tom M. Gomez in Google.

April: All right, very good Tom. Thanks so much, it was a pleasure.

tomgomezTom Gomez, Founder & Director of Transformations at the Edge

Mr. Gomez is an entrepreneur involved in research and development of innovative products and services in ehealth, medical devices, and digital media. He is inventor, co-inventor, or principal architect of the technologies underlying his entrepreneurial ventures.

Mr. Gomez is Founder & Executive Director of Transformations at the Edge LLC (TATE). TATE brings together federated collaboratives in support of the National Health IT Agenda. TATE seeks to inform, educate, and engage healthcare ecosystem participants including but not limited to, public health leaders, health system executives, health information technology professionals, government officials, academic faculty, physicians, and patient advocates in collaborative efforts to promote, and advance initiatives in support of the National Health IT Agenda. He is Founder of the Free Clinic Research & Educational Engagement Network (FreeNet), a Practice Based Research Network he is developing in close collaboration with the American Academy of Family Physicians National Research Network (AAFP NRN). He is the Principal Architect of “Health IT Transformations in Free Clinics” a program that is implementing “free” Electronic Health Records in Free Clinics around the country.

Mr. Gomez is a Member of the Research Steering Committee at the DARTNet Institute (DI). DI is a not-for-profit collaboration of Practice-Based Research Networks (PBRN) working to build a national collection of electronic health record (EHR) data, claims data, and patient reported outcomes data. The networks seek to blend quality improvement, effectiveness and translational research with a data driven-learning system. The learning system includes advanced performance measures and assistance with the development and deployment of clinical decision support systems. Nine such networks are members of DI, representing more than 85 healthcare organizations and more than 3,000 clinicians throughout the United States.

Mr. Gomez is a member of the Board of Stewards of Open Health Tools (OHT) an organization dedicated to improving the health of people through the transformation of health information technologies (health IT). TATE serves as the Program Office for the Open Health Tools Academic Outreach Project. Mr. Gomez co-developed and leads the Open Health Tools Academic Challenge, an annual event focused on promoting the development of open source Health IT applications.

Most recently, Mr. Gomez was CEO of BrainShield Technologies, Inc., a technology holding company he founded and managed for over a decade, with interests in ehealth and digital media. His early career spans engineering, planning and finance in aerospace, information technology, investment banking, and financial services industries. He has had budget responsibility for over $250 million in engineering programs; managed investment portfolios totalling over $450 million for high net worth individuals and corporations; and raised over $6 million in private funding for his entrepreneurial ventures.

Mr. Gomez holds a Bachelor of Science Degree in Industrial Engineering from the New Jersey Institute of Technology, and an Executive MBA from Oklahoma City University.


April Sage, CPHIMS, Director Healthcare Vertical, Online Tech 
April Sage has been involved in the IT industry for over two decades, initially founding a technology vocational program. In 2000, April founded a bioinformatics company that supported biotech, pharma, and bioinformatic companies in the development of research portals, drug discovery search engines, and other software systems.

Since then, April has been involved in the development and implementation of online business plans and integrated marketing strategies across insurance, legal, entertainment, and retail industries until her current position as Director Healthcare Vertical of Online Tech.



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