Electronic Health Records System

The vendor is required to provide for a cloud-based electronic health record (EHR) system tailored to the specific needs of the program of all-inclusive care for the elderly (PACE) program.
- His system will support integrated healthcare services for elderly participants, capturing activities of the interdisciplinary team (IDT), and must meet state and federal reporting requirements.
- EHR core requirements for clinical operations
• The system captures all participant encounters with templates specific to visit type and discipline.
• EHR supports the documentation (including standardized assessment tools and standard tests like MMSE, depression and anxiety test) and planning needs of the various members of the interdisciplinary care team (IDT).
- Medical records
• Readily accessible participant charts can be sorted by current and previous visits
• Patient summary face sheet/profile page with key vital information including key participant demographics, alerts, allergies, preferences, recent or open orders, authorizations, test results, medications, diagnoses, center services and links to the active care plan.
• Can categorize and view visits by discipline, specialty, date range or encounter type
• Confidential area on each chart for sensitive information such as grievance, behavioral health notes and aps reports
• Medical history section including scanned documentation
• Section to capture surgical history
• Section to gather social history
• Prompts or reminders for upcoming visit reminders – annual, mammogram, bone density, etc.
• Practice management features that outline the process for customized care routing capabilities for the pace programs and center’s business flow.
- Utilization management (UM)
• Functionality to facilitate the entire um lifecycle from authorization requests, referrals, status tracking, and approvals and denials to services including durable medical equipment (DME), social work (SW) procurement, extended care, home care, meals, day center services, contracted services, specialty services and procedures, and whether the visit was completed, and notes received.
• Can order and submit internal or external specialty referrals
• Service determination requests (SDR) capture and status – pending IDT review, approved, ordered, received, processing, completed, etc.
• SDR template and ability to alert IDT of request
• Can prioritize, expedite and monitor requests
• Link request or referral to care plan
• Allow for concurrent review for inpatient admissions
• Record and track outpatient procedures including preoperative planning, tests, status
- Clinic services
• System allows documentation of all encounters, provides guidelines and alerts as needed
• Presents discipline-specific and customizable documentation templates
• Templates facilitate participant visits and provide decision support cues to assist providers with soap notes and plans for follow-up care and services.
• Nursing – vitals, ambulance, dialysis, home health, NEMT
• Physician - icd-10 coding easily accessible with smart search with RAF identified and prompts for review
• Disease management - decision support features for chronic conditions and ability to access chronic medical problem list
• Can maintain a chronic problem list
• Can save common diagnoses
• Can maintain diagnoses on care management list
• Smart phrases – can create smart phrases and templates
• Standardized assessment tools and standard tests – MMSE, depression, anxiety, etc.
• Captures entire order lifecycle from order submission to order completion and tracks within patient chart including results review, disposition, completion, future orders, discontinue
• Can monitor ordering process from order date, auth date, appointment – requested, made, kept, results obtained and signed off
• Track and manage future orders with alerts and track order dependencies
• Immunizations - vaccine tracking, smart alerts, interface with CAIRS bidirectional
• Lab integration - in-house, quest, order, results, review, recurring, discontinue
• Radiology integration – orders, results, future orders
• Preventative health – can create alert or report for tests needed including blood pressure checks, cancer screenings, DEXA, etc.
• Can enter fall reports
• Can create alerts – er, admits, hospitalizations, SNF.
• Be able to review alert, update notes for discharge planning
• Tasking or activity assignment functionality to individuals or groups
• Can view task by individual or group
• Can see all activity/tasks by participant
- Medication administration and reconciliation (MAR)
• System facilitates medication management and adherence
• Prescription management - orders, standing orders, renewals
• E-prescribing: can send accurate prescriptions directly to pharmacy from point-of-care, tracking capabilities and allow for digital signatures
• Decision support and drug interaction alerts
• Can prescribe, administer and bill for vaccines medicare part b such as td, TDAP and Shingrix
• Pharmacy options provided by participant preference – preferred, mail, center
1. Discipline-based assessments and visit notes templates available in the system that include at a minimum:
• PCA services – toileting, showering, vitals
• Care manager – assessments, referrals
• Home care – home evaluation, ADL review
• Medical assistant – vitals, medication review
• Social worker – standard assessments, forms
• Occupational therapy
• Speech therapy
• Dietician - meals
• Ancillary services – dental, vision, hearing, podiatry, mental health
- Care planning
• Facilitates care planning with templates to capture expected outcomes/goals, planning, implementation activities and evaluation.
• IDT meeting tools which include calendar, alerts, reminders, updates
• Progress notes by IDT discipline
• Can assign, review, and approve
• Care plan reporting including signed version archive and printable plans for providers and Participants and family
• DME - order, approval, home care/services
• Smart phrases
• Can update diagnosis and plan from clinic progress note to care plan
- Practice management: enrollment and disenrollment
• Track prospects and aid in the collection of required documents, provide reminders and follow-up actions needed to complete enrollment activities.
• Marketing and prospect management from intake to enrollment which tracks referrals, outreach and contact attempts whether center or home visits
• Master participant/patient files - demographics, eligibility, next of kin, assignments
• Transition of care documentation
• Intake and level of care assessment
• Forms and required documents available to use and track as well as stored once completed – medical records request, advanced directives, consent, privacy, etc.
- Eligibility
• Check eligibility status, flag ineligible and deceased members; can parse out these members from reporting.
- Advanced care planning
• Capture planning activity and advance health care directives and POLST with ease of reference.
- Dashboards
• Dashboards that support work queues, a manager’s role to monitor staff workload, staff productivity and maintain staff work queues, and manager’s role to monitor overall work.
• Internal reporting must include tracking of encounters by team, staff, and site
• Tracking of medication usage and status
• Tracking of visits and charge tickets
• Support for workflow for orders for labs, radiology, and reference and assignment to worklist
- Appointments
• Calendar functionality to aid with scheduling clinic and center days, transportation, lunch/meals, specialty in-house and external appointments, outpatient procedures, etc.
• Can specify transportation mode needed and other appointment notes
• Can schedule across multiple IDT needs and calendars
• Schedule view by participant, discipline, center days, services
• Can order, approve and schedule
• Schedule can link to care plan
• Update attendance and completion
• Can note items to go home
• Provide appointment reminders to participants and family as needed
- Communication
• Track all participant contact attempts including telephone calls, provide appointment confirmations, send messages and reminders.
• Integrated instant-messaging system and “alerts, notification, and to-do’s” (“ants”) functionality
• Inquiry template to capture requests and task and track for follow-up
• Can communicate with external entities
- Task management
• Facilitate communication between center staff and assist with coordinating participant care needs.
• Send activities and tasks between clinic, center, acs
• Can flag information or provide alerts on participant chart or provider notes
• Notifications to staff and providers as needed
- Provider management
• Support a master list of providers uploaded from customer’s internal provider management application
• Master provider index and demographic data including licensure and credentials
• Able to handle providers with multiple NPIs
• Able to handle providers without NPIs
• Able to handle providers serving at multiple locations
• Can handle providers with multiple NPIs, capture provider demographics and multiple practice locations.
- Patient portal
• Participants and authorized caregivers are able to view or complete the following:
• Care plan
• Participant schedule and calendar
• Medical records information including visit summary, prescriptions, open orders, recent labs and test results
• Communicate with pace center and clinic
support the development and generation of care plans from non-clinical staff.
• Care plan builder that can generate a separate, member friendly care plan to be shared with the member
• Generate more detailed care plan to be shared with providers
• Document smart goals, prioritize goals and creation of member-specific goals
• Support integrated evidenced-based criteria for care plan guidelines
• Document progress toward goals over time, and creation of tailored interventions to support and achieve these goals
• Can download and share care plan in formats for both clinical and member
• Include options for languages  • Care plan template will identify participant’s current medical, physical, emotional, and social needs, including all needs associated with chronic diseases, behavioral disorders, and psychiatric disorders that require treatment or routine monitoring.
1. At a minimum, the care plan must address the following factors:
• Vision.
• Hearing.
• Dentition.
• Skin integrity.
• Mobility.
• Physical functioning, including activities of daily living.
• Pain management.
• Nutrition, including access to meals that meet the participant’s daily nutritional and special dietary needs.
• The participant’s ability to live safely in the community, including the safety of their home environment.
• Home care.
• Center attendance.
• Transportation.
• Communication, including any identified language barriers.  - IDT conference
• Support multiuser input to IDT documentation
• Generate IDT conference report in various formats depending on audience
- Alternate care setting (ACS)
• Monthly and quarterly progress notes that can be reviewed and signed off
• Segregate participants by location and site; attendance
• Enter acs service determination request and authorizations
• Assess for appropriateness
• Add to care plan
• Schedule acs assessment for sites
- Attendance
• Capture, track and report center and site attendance in real-time
• Can note specific encounter and appointment type
• Able to handle cancellations
• Able to add unscheduled attendees
- Integrated dashboards
• Virtual client management
• Schedule and track every service; view by discipline and by participant
- Transportation management
• Create transportation order and track status - schedule, verify
- Financial
• The system increases efficiency and accuracy of medical billing with workflows that do not require manual entry or processing with revenue cycle management.
• System features promote value-based care with real-time decision support.
• Participant visits and encounters generate billing codes and eliminate the submission of incomplete claims.
- Revenue cycle
• The system facilitates the revenue cycle with billing, coding and encounters reporting capabilities including coding with CPT, HCPCS, and DSM iv codes as part of CPT4 and a process to update those code sets
• Charge ticket - capture all visits and services; create encounter files
• Generates charge tickets that capture all services provided during an encounter
• RAF prompts, coding and chart review
• Streamlined billing generated from progress notes
• Create encounters and encounters file for reporting
• Vendor management
• IBNR – incurred but not recorded claims
• Medicare enrollment
• Track medicare and medical payments
- Reporting
• System can gather data and meet applicable pace compliance reporting and requirements for federal
regulators, e.g., file exports, standard reporting for HPMS.
• Required reporting templates are provided in the appendix for reference.
• LOPMR template
• Falls without injury template
• Emergency room urgent care visits template
• Appeals template
• Grievance template
• List of participant medical records (LOPMR) functionality
• Health plan management systems (HPMS) health outcomes
• HPMS risk adjustment tracking
•  Generate, print and export continuity of care document (CCD)
• CMS enrollment/disenrollment/PBP change
• CMS raps
• CMS PDE
• Datapace2 export
• Um reports including ability to export universe reports
• Clients can develop more comprehensive reports that integrate external client data.
•  Multiple file formats available for downloaded reports.
• Reports for follow up appointments, labs, radiology, missed appointments, specific drugs, specific diagnoses, quality metric gaps, HCC coding.
- Contract Period/Term: 3 years
- Questions/Inquires Deadline: March 19, 2025