1. keynote dominic mack morehouse school of medicine


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  • Only 4% percent of physicians reported having an extensive, fully functional electronic records system, and 13% reported having a basic system. Primary care physicians and those practicing in large groups, in hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records. Physicians reported positive effects of these systems on several dimensions of quality of care and high levels of satisfaction. Of the small number of respondents who had a fully functional system, 71% reported that their system was integrated with the electronic system at the hospital where they admit patients, as compared with only 56% of respondents with a basic system (P = 0.006). Among the 83% of respondents who did not have electronic health records, 16% reported that their practice had purchased but not yet implemented such a system at the time of the survey. An additional 26% of respondents said that their practice intended to purchase an electronic-records system within the next 2 years.
  • The Health Information Technology for Economic and Clinical Health Act, or the “HITECH Act”, was introduced in 2009 as a Government response to incentivize the steadfast adoption of health information technology (HIT) to achieve widespread adoption by 2014. The act represents an historic and unparalleled investment in HIT. “This investment lays the groundwork necessary to pursue the President’s goals related to improved health care quality and efficiency and will help transform the way health care is both practiced and delivered.” Source: http://energycommerce.house.gov/documents/20100727/Blumenthal.Testimony.07.27.2010.pdf
  • OPAS’ goal is to assist all providers to achieve meaningful use of EHR systems
  • While REC are encouraged to work with all providers they will initially focus on “Priority Settings” such as: Individual/small group practices focused on primary care (>10 PCPs) Public and Critical Access Hospitals (CAHs) Community Health Centers and Rural Health Clinics Other settings that predominantly serve uninsured, underinsured, and medically underserved populations
  • Initial Goal: Assist at least 100,000 primary care providers in priority settings in achieving Meaningful Use by 2012 Who makes up REC leadership? MDs, RNs, NPs, PharmD’s HIT professionals Former health care executives
  • RECs serve as a support center to make EHR implementation easier for providers throughout the entire process, or at any point along the way. RECs provide the following services, and other services to be identified by RECs necessary to assist providers to achieve Meaningful Use. Planning During the initial planning phase, the REC will work side by side a provider to conduct an EHR readiness assessment and develop the EHR project management plan. The REC will assist with: EHR review of your practice EHR vendor selection, identification, evaluation and negotiation Transition The REC lead a practice in transitioning from a paper-based health record environment to an interconnected, patient-centric care system. The REC will assist with: Support around practice and workflow redesign, needs prioritization, functional requirements HIT education, including provider-patient communication on issues related to privacy/security Implementation The REC’s goal is for a provider to achieve effective implementation of a certified EHR product. The REC will assists with: System implementation support, troubleshooting and requirements refinement HIE partnerships and preparations Operate & Maintain The REC will continue to support providers and keep them informed about national developments that may impact their work toward achieving meaningful use of a certified EHR system. The REC will assist with: Achieving meaningful use Maximizing payments, minimizing hassle Preparing for pay for performance measures Continuing to support practice transformation and EHR usability through all stages of meaningful use
  • The HITECH Act authorized CMS to develop Medicare and Medicaid Incentive programs to incentive eligible providers to adopt medical records and become meaningful users of HIT.
  • There are several unique challenges facing primary care providers, particularly in small practices or clinics, including: administrative and financial burden of implementing new system; operational, technical and infrastructure limitations; and provider and support staff ability to use a new system. Threat of information overload—both at the transitions of care and between disciplines Need to provide for data-sharing between clinical and public health agencies How to use HIT to improve the delivery of healthcare Addressing different views of ‘meaningful’ for different uses and users of HIT HIT system cost Uncertain ROI Lack of trained staff to support IT implementation. Overwhelming number of products / options Technology is not ready; lack of standards Finding an EHR to meet their needs (usability of EHR) Managing patient privacy and security concerns Disbelief in financial incentives
  • Under HITECH, several key programs, like the Medicare and Medicaid EHR Incentive Program and the Regional Extension Program, have been established to facilitate adoption of EHRs These investments are designed to work together to: Provide the necessary assistance and technical support to providers Enable coordination and alignment within and among states Establish connectivity to the public health community in case of emergencies Assure that the workforce is properly trained and equipped to be meaningful users of EHRs Together these programs build the foundation for every American to benefit from an EHR as part of a modernized, interconnected and vastly improved system of care Source: http://energycommerce.house.gov/documents/20100727/Blumenthal.Testimony.07.27.2010.pdf
  • TransforMED is the Academy’s “GO TO” entity for assisting practices implement the PCMH. They have organized their implementation offerings using eight domains that align with the more simplified graphical representation I have just presented to introduce you to the PCMH/Family Medicine model. The Academy will continue to use the PCMH terminology in its advocacy work with outside stakeholders promoting the medical home concept as a national health care reform platform.
  • 1. keynote dominic mack morehouse school of medicine

    1. 1. Regional Extension Centers, EHRs & Meaningful Use Dominic H. Mack MD,MBA Project Director GA-HITREC Deputy Director National Center for Primary Care Morehouse School of Medicine [email_address] .
    2. 2. <ul><li>In 2006, about 65,700 nontraumatic lower-limb amputations </li></ul><ul><li>More than 60% of nontraumatic lower-limb amputations </li></ul><ul><li>285 million people internationally </li></ul><ul><li>US Health Disparities & Preventable Diseases </li></ul><ul><li>Diabetes </li></ul><ul><li>US ranks 37 th in Health Care performance </li></ul>
    3. 3. EHR Implementation Remains Limited Among Physicians DesRoches, C., et al, “Electronic Health Records in Ambulatory Care - A National Survey of Physicians” New England Journal of Medicine, 2008;359:50-60. (http://www.nejm.org/doi/pdf/10.1056/NEJMsa0802005) A 2008 national survey of 2,758 physicians found positive effects of EHR systems on quality of care and satisfaction
    4. 4.
    5. 5. <ul><li>The Centers for Medicare & Medicaid Services (CMS) mandates that all physicians/hospitals and payers exchange key business transactional data using the HIPAA 5010 format via Electronic Data Exchange (EDI) by 1/1/2012. </li></ul><ul><li>Transition from HIPAA 4010 to HIPAA 5010 </li></ul><ul><ul><li>Adds functionality to the enrollment, eligibility, inquiry, claim, claim inquiry, remittance, referral/authorization and premium payment transactions </li></ul></ul><ul><ul><li>Eliminates redundancy and ambiguity in the usage of transaction standards </li></ul></ul><ul><ul><li>Clarifies NPI instructions and provide a structure for better usage </li></ul></ul><ul><ul><li>Establishes a platform for the adoption of International Classification of Diseases, 10th Edition (ICD-10) codes </li></ul></ul><ul><ul><li>Reduces reliance on trading partner Companion Guides for Electronic Data Interchange (EDI) transactions </li></ul></ul><ul><ul><li>Calls for HIPAA 5010 Trading Partner Testing by January 1, 2011 and adoption by January 1, 2012 </li></ul></ul><ul><li>Opportunities </li></ul><ul><ul><li>Drive the administrative simplification and transparency agenda </li></ul></ul><ul><ul><ul><li>Consistent use of transaction sets </li></ul></ul></ul><ul><ul><ul><li>Consistent communication and testing approach with trading partners including UnitedHealthcare </li></ul></ul></ul><ul><ul><ul><li>Consistent data and data context across all health plans easing complexity for practice management systems and vendors </li></ul></ul></ul><ul><ul><li>Reduce variation and cost of infrastructure and support of EDI transactions across the industry </li></ul></ul>HIPAA 5010 Overview Confidential property of Unitedhealth Group. Do not distribute or reproduce without express permission of Unitedhealth Group.Confidential property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
    6. 6. Example ICD-9 to ICD-10 changes Confidential property of Unitedhealth Group. Do not distribute or reproduce without express permission of Unitedhealth Group. More than just a crosswalk ICD-9 ICD-10 14,000 Diagnosis Codes 4,000 Procedure Codes 68,000 Diagnosis Codes 87,000 Procedure Codes Angioplasty (procedure codes) 1 code 39.50 Angioplasty (procedure codes) 854 different codes 047K047 Specifying body part, approach and device Pressure Ulcer Codes (diagnosis codes) 7 codes 707.00-707.99 Show location, but not depth Pressure Ulcer Codes (diagnosis codes) 125 different codes L89.131 Specific location, depth, severity, occurrence <ul><li>No equivalent ICD 9 Code </li></ul><ul><li>Indicated through notes and </li></ul><ul><li>other methods </li></ul>Y71.3 Surgical instruments, materials and cardiovascular devices associated with adverse incidents Autopsy 89.8 No ICD 10 code
    7. 7. HITECH: Catalyst for Transformation Pre 2009 2009 2014 A system plagued by inefficiencies EHR Incentive Program and 62 Regional Extension Centers Widespread adoption & meaningful use of EHRs
    8. 8. Office of the National Coordinator (ONC) Big Picture Goal … <ul><li>Regional Extension Center </li></ul><ul><li>Community College Workforce </li></ul><ul><li>Communities of Practice </li></ul><ul><li>Health Information Technology Research Center (HITRC) </li></ul>Paper-Based Practice Support Network REC-Provider Partnership Fully Functional EHR Education and Outreach • Workforce • Vendor Relations • Implementation • Workflow Redesign • Functional Interoperability • Privacy and Security • Meaningful Use Population Health Health Care Efficiency Patient Health Outcomes
    9. 9. O ffice of the N ational C oordination: Organization <ul><li>I. The Office of Deputy National Coordinator for Programs & Policy </li></ul><ul><li>The Office of Standards and Interoperability , standards, security, certification, NHIN, Federal Health Architecture and the CONNECT program; </li></ul><ul><li>The Office of State and Community Programs , HIE & Beacon Communities </li></ul><ul><li>The Office of Policy and Planning , policy development, including privacy and security policy, and is liaison with legal affairs and legislative </li></ul><ul><li>The Office of Provider Adoption Support , RECs ,HIT workforce development; </li></ul><ul><ul><ul><ul><li>II. The Office of Deputy National Coordinator for Operations </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The Office of Communications </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The Office of Mission Support, </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The Office of  Oversight, </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The Office of Grants Management </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>III. The Office of Economic Analysis and Modeling </li></ul></ul></ul></ul><ul><ul><ul><ul><li>IV. The Office of the Chief Scientist </li></ul></ul></ul></ul><ul><ul><ul><ul><li>V. The Office of the Chief Privacy Officer , </li></ul></ul></ul></ul>
    10. 10. Office of Provider Adoption Support (OPAS) Goal: Assist All Providers to Achieve Meaningful Use of EHR Systems Community College Consortium Provider Adoption Services Provider Adoption Services Meaningful Use Regional Extension Centers (RECs) Health Information Technology Research Center (HITRC)
    11. 11. REC Focus: Priority Primary Care Providers <ul><li>While RECs are encouraged to work with all providers, they will initially focus on “Priority Settings”: </li></ul><ul><ul><li>Individual/small group primary care practices (<10 PCPs) </li></ul></ul><ul><ul><li>Public Hospitals and CAHs </li></ul></ul><ul><ul><li>Community Health Centers and Rural Health Clinics </li></ul></ul><ul><ul><li>Other settings that serve medically underserved populations </li></ul></ul>
    12. 12. 62 RECs Cover 100% of the USA <ul><li>Not-for-profit organizations </li></ul><ul><li>Experts in EHR adoption </li></ul><ul><li>Provide “on-the-ground” technical assistance </li></ul><ul><li>Extensive stakeholder partnerships </li></ul><ul><li>Focused on achieving MU </li></ul>Goal: 100,000 priority primary care providers achieve meaningful use (MU) by 2012
    13. 13. GA-HITREC (GA HIT Regional Extension Center) <ul><li>Statewide Statistics </li></ul><ul><li>PCPs: </li></ul><ul><li>15,563 </li></ul><ul><li>Priority PCP: </li></ul><ul><li>8040 </li></ul><ul><li>Target Numbers; </li></ul><ul><ul><li>5220 providers </li></ul></ul><ul><ul><li>56 CAHs & Rural Hospitals </li></ul></ul><ul><li>Georgia Population: </li></ul><ul><ul><li>9,965,744 </li></ul></ul><ul><li>Total patients served (projected): </li></ul><ul><li>: 2.8 million </li></ul>
    14. 14. National Center for Primary Care, Morehouse School of Medicine Community Oriented Technology Pyramid of Providers
    15. 15. NCPC/MSM Partners GA DCH Office of Health Information Technology and Transparency GA State Medical Association GA Academy of Family Physicians GA Partnership for Telehealth Hometown Health GA Institute of Technology Southern Polytechnic GA Association for Primary Health Care GA-HIE Andrew Young School of Policy Studies GA Hospital Association GA State Office of Rural Health CHW GMCF (QIO) CAAP Hispanic Health Coalition of GA GA Technical Institute Kibbe Group, Founding Director of the Center for HIT for the of Family Physicians Morehouse School of Medicine Office of Sponsored Research Administration Kids Health First Pediatric , Independent Practice Association Statewide Area Health Education Centers Network GA Chapter of the of Pediatrics Medical College of GA Amerigroup Technical College System of GA (TCSG) University System of GA Americhoice WellCare of GA Macon State College
    16. 16. GA-HITREC CRM Lifecycle No Cost Support for PPCPs EHRs NextGen eClinical Works e-MDs Greenway MIE Target Providers PPCPs Non-PCPCs Specialist <ul><li>Partner Relations </li></ul><ul><li>Communities of Practice </li></ul><ul><li>Best Practices </li></ul><ul><li>Program Management </li></ul><ul><li>Project/Site Information </li></ul><ul><li>Key Milestone Details </li></ul><ul><li>Practice Demographics </li></ul><ul><li>Site Information </li></ul><ul><li>Vendor Relations </li></ul><ul><li>Vendor Management </li></ul><ul><li>Targeted Marketing Campaigns </li></ul><ul><li>Lead Management </li></ul><ul><li>Signing up Providers </li></ul>© Copyright 2010 All Rights Reserved.
    17. 17. Comprehensive Support throughout the Entire EHR Implementation Process Readiness assessment EHR system selection <ul><li>Practice workflow redesign </li></ul><ul><ul><li>HIT education & training </li></ul></ul><ul><ul><li>Achieve meaningful use </li></ul></ul><ul><ul><li>Prepare for future pay for performance </li></ul></ul><ul><ul><li>EHR implementation </li></ul></ul><ul><ul><li>Partnering with state & local HIEs </li></ul></ul>Operate & Maintain 4 Primary goal: Give providers as much support as possible Plan 1 Transition 2 Implement 3
    18. 18. RECs Cover the Full Range of Services Interoperability & HIE Assist providers in meeting functional interoperability requirements (GA-DCH HITT) Implementation Support Provide EHR project management support Meaningful Use Assist providers on achieving Meaningful Use objectives Practice & Workflow Design Assist practices in improvement of daily operations Privacy & Security Implement best practices to protect patient information Outreach & Education Share best practices to select, implement, and meaningfully use EHRs Vendor Selection Assess practice’s IT needs and help select/ negotiate vendor contracts Workforce Provide EHR training to providers and staff REC Services
    19. 19. After EHR Integration Halfpenny’s ITF-Based “Lab Hub” Solution Drives clinical lab test results into EHRs as structured data… provides quality results reporting and meets requirements for Meaningful Use
    20. 20. Meaningful Use & Provider Incentive Program © Copyright 2010 All Rights Reserved.
    21. 21. Meaningful Use & Provider Incentive Program © Copyright 2010 All Rights Reserved.
    22. 22. <ul><li>Issue Medicare incentive payments to eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) that are meaningful users of certified EHR technology . </li></ul><ul><li>Issue Medicaid incentive payments to eligible professionals and hospitals for efforts to adopt, implement, or upgrade certified EHR technology </li></ul>Meaningful Use Established Payments HITECH Act © Copyright 2010 All Rights Reserved.
    23. 23. Meaningful Use Criteria- Stage 1 <ul><li>25 total objectives/measures for EPs and 24 for EH </li></ul><ul><li>Core set =15 for EPs and 14 for EHs </li></ul><ul><li>Menu set = 10 (choose 5 out of the 10) </li></ul><ul><li>Reporting Period= 90 days yr 1, one year subsequently </li></ul><ul><li>If exclusion applies EP or EH may not have to meet objective </li></ul><ul><li>3 core, and 3 additional quality measures in 2011 and 2012: blood-pressure level, tobacco status and adult weight screening </li></ul>© Copyright 2010 All Rights Reserved.
    24. 24. Meaningful Use Criteria- Stage 1 <ul><li>Core set: All 15 Measures Required </li></ul><ul><li>Demographics (50%) </li></ul><ul><li>Vitals: BP and BMI (50%) </li></ul><ul><li>Problem list: ICD-9-CM or SNOMED (80%) </li></ul><ul><li>Active medication list (80%) </li></ul><ul><li>Medication allergies (80%) </li></ul><ul><li>Smoking status (50%) </li></ul><ul><li>Patient clinical visit summary (50% in 3 days) </li></ul><ul><li>Hospital discharge instructions (50%) - or - Patient with electronic copy (50% in 3 days) </li></ul><ul><li>e-Prescribing (40%) </li></ul><ul><li>CPOE (30% including a med) </li></ul><ul><li>Drug-drug and drug-allergy interactions (functionality enabled) </li></ul><ul><li>Exchange critical information (perform test) </li></ul><ul><li>Clinical decision support (one rule) </li></ul><ul><li>Security risk analysis </li></ul><ul><li>Report clinical quality (BP, BMI, Smoke, plus 3 others) </li></ul><ul><li>Menu set: Select 5 of 10 </li></ul><ul><li>Drug-formulary checks (one report) </li></ul><ul><li>Structured lab results (40%) </li></ul><ul><li>Patients by conditions (one report) </li></ul><ul><li>Send patient-specific education (10%) </li></ul><ul><li>Medication reconciliation (50%) </li></ul><ul><li>Summary care record at transitions (50%) </li></ul><ul><li>Feed immunization registries (perform at least one test) </li></ul><ul><li>Feed syndromic surveillance (perform at least one test) </li></ul><ul><li>Send reminders to patients for preventative and follow-up care (20% > 65yrs. < 5yrs.) </li></ul><ul><li>Patient electronic access to labs, problems, meds and allergies (10% in 4 days) </li></ul>
    25. 25. Eligible Providers <ul><li>Medicare FFS </li></ul><ul><li>Eligible professionals (EPs) </li></ul><ul><li>Eligible hospitals and critical access hospitals (CAHs) </li></ul><ul><li>Medicare Advantage </li></ul><ul><li>MA EPs </li></ul><ul><li>MA-affiliated eligible hospital </li></ul><ul><li>Medicaid </li></ul><ul><li>EPs </li></ul><ul><li>Eligible hospitals </li></ul>© Copyright 2010 All Rights Reserved.
    26. 26. <ul><li>Eligible Professionals (EPs) </li></ul><ul><li>Physicians (Peds have special eligibility & payment rules) </li></ul><ul><li>Nurse Practitioners (NPs) </li></ul><ul><li>Certified Nurse-Midwives (CNMs) </li></ul><ul><li>Dentists </li></ul><ul><li>Physician Assistants (FQHC or RHC that is directed by a PA) </li></ul><ul><li>Eligible Hospitals </li></ul><ul><li>Acute Care Hospitals </li></ul><ul><li>Children’s Hospitals </li></ul>Medicaid Eligible Providers © Copyright 2010 All Rights Reserved.
    27. 27. Medicare Eligible Providers <ul><li>Eligible Professionals (EPs) </li></ul><ul><li>Doctor of Medicine or Osteopathy </li></ul><ul><li>Doctor of Dental Surgery or Dental Medicine </li></ul><ul><li>Doctor of Podiatric Medicine </li></ul><ul><li>Doctor of Optometry </li></ul><ul><li>Chiropractor </li></ul><ul><li>Eligible Hospitals </li></ul><ul><li>Acute Care Hospitals </li></ul><ul><li>Critical Access Hospitals (CAHs) </li></ul>© Copyright 2010 All Rights Reserved.
    28. 28. Medicare First Calendar Year in which the EP Receives an Incentive Payment Calendar Year 2011 2012 2013 2014 2015 & Later 2011 $18,000 2012 $12,000 $18,000 2013 $8,000 $12,000 $15,000 2014 $4,000 $8,000 $12,000 $12,000 2015 $2,000 $4,000 $8,000 8,000 $0 2016 $2000 $4,000 $4,000 $0 Total $44,000 $44,000 $39,000 $24,000 $0 © Copyright 2010 All Rights Reserved.
    29. 29. Medicaid First Calendar Year in which the EP Receives an Incentive Payment Calendar Year 2011 2012 2013 2014 2015 2016 2011 $21,250 2012 $8,500 $21,250 2013 $8,500 $8,500 $21,250 2014 $8,500 $8,500 $8,500 $21,250 2015 $8,500 $8,500 $8,500 $8,500 $21,250 2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 2017 $8,500 $8,500 $8,500 $8,500 $8,500 2018 $8,500 $8,500 $8,500 $8,500 2019 $8,500 $8,500 $8,500 2020 $8,500 $8,500 2021 $8,500 Total $63,750 $63,750 $63,750 $63,750 $63,750 $63,750 © Copyright 2010 All Rights Reserved.
    30. 30. Hospital Incentive Calculations <ul><li>Calculations: </li></ul><ul><ul><li>multiplying a $2 million base rate plus an inpatient discharge rate times a Medicare share fraction and then times a transition factor. </li></ul></ul><ul><ul><li>The discharge rate will vary, but larger hospitals will have larger discharge rates. </li></ul></ul><ul><ul><li>The transition factor changes every year for four years to create a step-down incentive payment structure. </li></ul></ul><ul><ul><li>Medicare will only make incentive payments to an eligible hospital for a maximum of four years. </li></ul></ul><ul><ul><li>The transition factor after the fourth payment year is zero. </li></ul></ul><ul><li>An eligible hospital can begin to receive payments in fiscal year 2011, and CMS will end all incentive payments to all hospitals after 2015. </li></ul><ul><li>. </li></ul>
    31. 31. “ Phased-in series of improved clinical data capture supporting more rigorous and robust quality measurement and improvement.” For HHS…“These goals can be achieved only through the effective use of information to support better decision-making and more effective care processes that improve health outcomes and reduce cost growth” Connecting for Health, Markle Foundation “Achieving the Health IT Objectives of the American Recovery and Reinvestment Act” April 2009 HHS’ overall objective is to ensure that providers make use of, and patients have access to, clinically relevant electronic information, not just existence of technology 3 stages of meaningful use
    32. 32. Implementation vs. Adoption
    33. 33. EHR Adoption Training
    34. 34. EHR Adoption Challenges Financial Organization Change <ul><li>Expense of system </li></ul><ul><li>Uncertainty around ROI </li></ul><ul><li>Provider and staff productivity </li></ul><ul><li>Uncertainty about financial incentives </li></ul><ul><li>Disruption of workflow and productivity </li></ul><ul><li>Privacy and security concerns </li></ul><ul><li>Maintaining patient centeredness and satisfaction </li></ul><ul><li>Concerns about technically supporting a system </li></ul><ul><li>Lack of necessary computer skills </li></ul><ul><li>Finding the right EHR to suit practice needs (“usability”) </li></ul><ul><li>Having the right IT staff in place </li></ul><ul><li>Possibility of information overload </li></ul>Technical © Copyright 2010 All Rights Reserved.
    35. 35. EHR “ A medical tool that connects, shares knowledge, and supports best practices for patient care”
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    48. 48. Building an Interconnected, Patient-Centric Care System Health Information Exchange © Copyright 2010 All Rights Reserved.
    49. 49. Quality and Safety Health Information Technology Practice Management Practice-based Care Team Practice Services Continuity of Care Services Care Management Access to Care and Information The Family Medicine Model and the TransforMED Approach Great Outcomes Patient Experience Quality Measures Health Information Technology Practice Organization
    50. 50. Dominic H. Mack MD,MBA Project Director GA-HITREC Deputy Director National Center for Primary Care Morehouse School of Medicine [email_address] Thank You Visit the GA-HITREC Portal: www.ga-hitrec.org Call GA-HITREC toll free: 877-658-1990 Email GA-HITREC: [email_address]