Primary care physicians, meet your regional extension centers

• Regional extension centers can help you select and implement an electronic health record system and attest to meaningful use.


• There are 62 RECs spread across the country.

Implementing an electronic health record (EHR) system in your primary care practice is no small task. You must consider hundreds of individual elements about the system itself, plus the cost, the hit to your practice's productivity during installation, and, of course, compliance with federal regulations.

Regional extension centers Z(RECs, pronounced R-E-Cs) are a free, or nearly free, tool designed to assist you with the process, and with attesting to meaningful use, so that you can receive your share of the incentive funds and begin to exchange health information with the greater healthcare community in your area. In fact, 62 RECs are spread throughout the country.

THE REC MISSION

In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act established the Health Information Technology Extension Program. Its mission, according to Sec. 3012 of the HITECH Act, is "to assist healthcare providers to adopt, implement, and effectively use certified EHR technology that allows for the electronic exchange and use of health information."

The Office of the National Coordinator for Health Information Technology (ONC) of the U.S. Department of Health and Human Services (HHS) further defined the REC programs:

"The RECs will support and serve healthcare providers to help them quickly become adept and meaningful users of [EHRs]. RECs are designed to make sure that primary care clinicians get the help they need to use EHRs. RECs will:
■ "provide training and support services to assist doctors and other providers in adopting EHRs,
■ "offer information and guidance to help with EHR implementation, [and]
■ "give technical assistance as needed.
■ "The goal of the program is to provide outreach and support services to at least 100,000 priority primary care providers within 2 years."

Practices with only a few physicians—and limited budgets—now have access to free, or nearly free, assistance from health information technology (HIT) experts who will help you choose the most suitable EHR for your practice, guide you through its implementation, and then assist you as you attest to meaningful use with the government. But not all RECs are alike. And this fact has led to some challenges for both physicians and vendors.

ONE EHR VENDOR'S UNIQUE JOURNEY

 

Jonathan Bertman, MD, FAAFP

In an effort to streamline their own operations and provide what they believed were the best options for the physicians they serve, some RECs created "preferred vendor lists" that were populated mostly with larger EHR vendors. The reasoning behind this strategy seems to be that these RECs were trying to be forward-thinking by raising the bar on which EHRs they recommended to their constituency. In following this path, they expected the EHRs they selected to include functionality that is not required by the ONC for attesting to meaningful use.By itself, that's not necessarily a bad thing. The RECs, however, unintentionally excluded EHRs that they later learned were a better fit for the smaller primary care practices the RECs were created to help in the first place.

For example, one EHR that's popular with physicians because of its functionality and lower cost is Amazing Charts. Built from scratch by a Rhode Island family physician, Amazing Charts has won awards for its design. Even so, the company struggled to get its EHR onto the RECs' preferred vendor lists due to its lack of certain modules and components even though the inclusion of these functions, such as a SaaS (software as a service) component, is not required to achieve level one meaningful use.

"There's a huge learning curve the RECs have gone through," says Jonathan Bertman, MD, FAAFP. Bertman founded Amazing Charts in 2001 after constructing an EHR in 1999 and spending 2 years perfecting it through trial, error, and feedback from other physicians. Today, Amazing Charts is used in more than 3,700 practices nationwide.

"When the ONC first announced the REC project, like every other EHR vendor, we realized we needed to be listed by these RECs if we were to compete. We contacted the RECs and received their request for proposals [RFP]," he says.

"Every single REC had a different RFP, but they all asked essentially the same questions," he adds. "Are you certified? How do you do this? How do you do that? While filling them all out, we realized they weren't based on any sort of science. It was just a very onerous process that I think smaller EHR companies couldn't do because of resources."

From that process, many RECs ruled out Amazing Charts immediately because it didn't have a built-in SaaS model. Bertman soon discovered that all of these RECs had in place different processes, and very few of them were truly vendor agnostic, as they were mandated to be. He felt it wasn't fair that his tax dollars were being used to promote his competitors' EHRs.

"I assumed that this wasn't the ONC's intention, so I sent letters to the RECs that had refused us," Bertman says. "I asked them who made these decisions and how the decisions were made. The comments we got back were vague. No one wanted to be pinned down. So we decided not to fight every single REC."

Instead, Amazing Charts went directly to the ONC to discuss its experiences. The company scheduled a meeting with David Blumenthal, MD, then national coordinator for HIT in HHS.

"But on the morning of the meeting, he cancelled, and we ended up sitting with other people," Bertman says. The group made five recommendations that day:
■ RECs with a preferred vendor list should be required to disclose everyone who's on the board making decisions.
■ Vendor selection committees should be made up of a majority of physicians from small practices or staff from small practices.
■ A universal application process should be created so that EHR companies can apply just once, not 62 different times.
■ The RECs' studies on usability should be disclosed.
■ The ONC should enforce REC vendor neutrality. An REC should not have a preferred list. Having a preferred list means the government is recommending certain products over others, which is unfair.

"Their response to our recommendations was to say that the process could not be changed," Bertman says. "Nothing really happened after we approached the ONC.

"But now, we're listed with many RECs. And it was the physicians that made the difference," he says. "They got all the marketing hype, and they didn't buy any of it. They weren't signing up in the numbers the RECs needed, [and] they weren't agreeing to working with the preferred vendors, and at that point the RECs began coming back to us. The RECs first said 'no thanks' and rejected us and then came back looking for a way to include us."

Amazing Charts is now on most RECs' lists, and Bertman says the company is working to get on the others.

"My sense is that the RECs needed to go through that process," he says. "They're composed mostly of IT people and quality assurance people from health insurers. They thought they understood usability and what doctors needed, but they didn't, and doctors pushed back."

Therefore, the RECs changed their approach, because their funding depends on them hitting their targets.

COLLABORATION SEEN AS KEY TO SUCCESS

 

Scott Irwin

"Working with the RECs has been an ongoing educational process from a vendor standpoint, and one that is really starting to benefit both our clients and the EHR vendor community," says Scott Irwin, director of state engagement and REC support for NextGen Healthcare.

"The RECs were originally put on short timeframes to begin working with physicians and EHR vendors toward meaningful use," he says. "This initial push created several very quick—and sometimes rushed—vendor selection processes."

For instance, according to Irwin, many RECs had to start their vendor selection even before ONC-ATCB (authorized testing and certification body) certification of EHRs was open for the vendors. In addition, the RECs quickly had to assess the physician landscape in the geographic areas they cover to determine:

■ how many physicians already had EHR systems,
■ what services they would need,
■ which EHR vendors had an existing footprint in which areas, and
■ what obstacles physicians might face when purchasing EHR systems.

This challenge, along with an effort by some RECs to be vendor-neutral, created some initial hurdles to overcome for both the RECs and the EHR vendors, Irwin says, adding that the experience had the benefit of demonstrating to vendors that effectively helping physicians attest to meaningful use would require collaboration between all parties.

"How the relationships were established varied from state to state," Irwin says. "But out of 62 RECs, today we are now collaborating closely with 57 of them to get providers to meaningful use."

According to Irwin, now that RECs and EHR vendors are collaborating, the industry is beginning to see success stories. Through the Meaningful Use Vanguard (MUV) program, many states have highlighted physicians who have attested to meaningful use already with the help of a local REC and a vendor.

"One of our clients, Peter Muir, [MD] of Springfield Center for Family Medicine in Ohio, was honored by the ONC this summer for his success in achieving meaningful use and for helping others through MUV," Irwin says. "Another client, Complete Family Medicine, will be recognized [in October] as the first practice to reach meaningful use in Missouri."

Most of these early milestones were achieved with physicians and practices that had purchased an EHR system before REC involvement, Irwin says. "However, with these successes starting to mount up, the RECs now can provide more value to the physicians who need help purchasing, implementing, going live, and then attesting to meaningful use."

For RECs to continue beyond the initial government funding, Irwin says, they need to bring together—for the benefit of both physicians and EHR vendors—all the critical initiatives in their areas. This effort would include:
■ health information exchange (HIE),
■ medical homes,
■ accountable care compliance, and
■ any payer-driven programs that incentivize providers for quality.

"Physicians who perceive value from their RECs during the meaningful use attestation process will continue to seek help while they navigate all the upcoming changes in healthcare IT," Irwin says.

RECs have gotten the message. Their purpose is to help physicians, not force unwanted technology on them. They're listening to what doctors are saying. Consequently, they're succeeding like never before.

"Now, RECs are going to their constituents and asking, 'What is it that you really need?' as opposed to the technologist on the board saying, 'What you docs need is an EHR that has the ability to send out an order and has practice management and has a SaaS version and has XYZ,' " Bertman says. "That was just them guessing what was needed. When they finally asked, the docs said, 'We just need something that lets us document—without costing too much—and gets us home in time for dinner.' Once the RECs started asking, things began to work out."

ONE REC'S PERSPECTIVE

Some RECs do not do all of their own implementation work. Instead, they contract it out to EHR implementation organizations, such as the Massachusetts eHealth Collaborative (MAeHC).

 

Micky Tripathi

MAeHC is not the REC in Massachusetts. The REC in that state is the Massachusetts eHealth Institute (MeHI). MAeHC is, however, the REC in New Hampshire, as well as being a contractor to the MeHI. MAeHC also contracts with the New York eHealth Collaborative, doing EHR implementation work for 400 to 500 physicians, as well as to the Rhode Island Quality Institute.

It's not unusual for different RECs to use different operational models. Some RECs provide their own staffs and complete all their own implementation work, whereas others contract much of their implementation work out to other implementation organizations.

"As these RECs receive the federal grant money, they define their programs and sign contracts with implementation organizations, such as the MAeHC, who actually provides the services to the physicians," says Micky Tripathi, president and chief executive officer of MAeHC and the MAeHC Professional Services Corp.

In those states, physicians can select who will implement their EHRs from a list of implementation organizations that their REC already has vetted.

"From the physician's perspective, it's a group of organizations that have already been certified, the price has been negotiated, and they know that the quality will be there because it's already been pre-negotiated for them," Tripathi says.

This situation enables the physicians to make choices based on their own experiences and in their own interests—a hallmark of the ONC's REC program.

"The MAeHC has a longer history in this than most RECs because we were founded in 2004. The origins of the REC program in some ways stem from the lessons learned from our organization and the primary care information project," says Tripathi.

MAeHC also is a nonprofit organization and part of the Massachusetts Medical Society, so it is closely tied with the physicians there.

"We have pretty deep physician roots, and as a nonprofit, a lot of the physicians who work with us like the idea that we're very close to the medical society, so they can trust that we only have the interest of the mission that we subscribe to," Tripathi says.

RECs receive core funding from the federal government that goes to creating the organization. On top of that they receive "direct-assistance funding" that amounts to $5,000 per physician signed to a contract. Unlike the core funding, which is paid up front, the direct-assistance is paid out incrementally according to the REC's performance benchmarks for each physician.

LIST OF REC SERVICES

"We go in, and if they don't already have an EHR in mind, we help them with the vendor selection process," Tripathi says. "We don't choose the vendor for them, but we work with them to think through the differences among the vendors to find the best option for them. Some of the RECs have a fixed list of vendors that the physicians are supposed to choose from, but we don't get involved in that. Again, each REC is different.

"Then, we do a preliminary assessment of the practice's readiness from a technical, business, organizational, staff, and change management perspective," Tripathi says. "Our experience has been that it's really the people issues more than the technical issues that you'll have to deal with. Then we go through their workflow and look at the gap between where they are and where they need to be. We identify their needs. Hardware, software, different skill sets, staff training, staff changes, workflow re-orientation from paper to electronics.

"Then we help them through the actual implementation of the system, supplement the training they'll get from the vendor, and make sure they have a smooth go-live."

At that point, the MAeHC passes the practice over to the vendor. "We make sure they have a smooth transition to the vendor's support organization," Tripathi says.

SELECTING THE BEST EHRS FOR THEIR PHYSICIANS

Unlike some RECs, the MAeHC New Hampshire REC does not compile a preferred-vendor list.

"We found that, in the market, that was a barrier more than anything else," Tripathi says. "We certainly fell prey to this, too, thinking that these preferred-vendor relationships would provide value. What we ended up seeing, though, as a number of RECs went through that process, is that they got into these bare-knuckle negotiations with the EHR vendors for what appeared to be not much more favorable pricing terms. It also ended up closing out some vendors, which sent the message 'you're not invited here.' The 'marriage' ended up starting out on rocky footing because we're arguing with the vendors before there are even any sales.

"We decided that this wasn't the right way to start. We'll work with any vendor in the state of New Hampshire. We really just want this to be a win-win for everyone," Tripathi says.

Because many EHRs were excluded from the preferred-vendor lists for lacking the functionality that is not actually required to attest to meaningful use, the question has been raised as to why RECs went in this direction in the first place.

"It's a fair question," Tripathi says. "I think that in almost every case, it was very well-intentioned. The RECs were thinking that this was the way of the future, and that they needed to build a scalable business model that would serve the physician better. But then you end up with the unintended consequence of closing out some vendors when you really didn't mean to do that. I don't think it was done with malicious intent.

"We've been in the market long enough to know that you can't predict what the market will do, and you can't dictate what the market will be, so you have to follow where it wants to go and try to get it aligned with the meaningful use goals," Tripathi says. "The vendors are our partners. In the long run, the RECs are just a tiny little blip on the screen. The RECs will eventually go away, and the EHR vendors will be the ones who carry this forward."

ONE SIZE DOES NOT FIT ALL

Working with RECs will differ from one region to the next. Some RECs, following an ONC requirement that RECs provide or match 10% of the federal funds, require physicians to make a payment up front to collect those funds, usually less than $1,000.

Some RECs choose not to collect that 10%, opting instead to provide all of their services for free—from initial contact through assisting the practice with attestation to meaningful use—and documenting all of their out-of-pocket expenses over and above those reimbursed by the federal funds, to show the ONC that they provided value equal to the 10% as goods and services.

Other RECs use a different business model. The Rhode Island REC, for example, offers its practices a portion of the $2,500 in federal funding it receives following a practice's successful attestation of meaningful use if the practice completes the EHR implementation with the REC.

In some states, physicians can contract directly with an REC's subcontracted implementation organization. In Rhode Island for example, physicians can negotiate the final cost of implementation services directly with the MAeHC.

Why the difference among RECs? The ONC requires RECs to present a sustainable business model that would show revenue in years three and four. The RECs that charge do so because, for them, it's the only way to fulfill the requirement.

"The REC program model varies by market. In New Hampshire, we believe that physicians should not have to pay for this," Tripathi says. "It's supposed to be a subsidy program that gets them up and running on an EHR, and the minute you start charging them, you've created a barrier. So, on principle, we feel they shouldn't have to pay. But from a market perspective, it also introduces a barrier to adoption that we don't want to introduce," Tripathi adds.

If the process sounds complicated it is. The process is intended, however, to enable both physicians and RECs to make sound decisions based on their local knowledge rather than having them conform to standards and procedures arbitrarily set by the federal government.

CHALLENGES TO RECS

The biggest challenge to the REC process thus far is getting the word out to physicians that the RECs even exist. Even though RECs work hard at outreach in their areas, many practices are so overwhelmed that mail from an REC ends up in the reception desk's circular file before physicians get to see it.

It's too important of an opportunity to let go undiscovered, however. If you have worked with an REC, inform your fellow physicians so they, too, can consider whether to involve an REC in their EHR selection and implementation decisions.

"There's just so many things going on for physicians," Tripathi says. "I think they get really confused with the meaningful use incentive payments versus the REC. It's incredibly complicated. Even those of us who spend all of our working hours thinking about it get confused. I can't imagine how physicians are supposed to sort through all of this stuff and not kill people as they're practicing medicine."

Tongue-in-cheek as that may be, Tripathi makes an important point. The reason RECs exist is to help physicians get through the EHR selection and implementation process with their sanity intact.

IMPORTANT POINTS TO REMEMBER WHEN DEALING WITH RECS

RECs are here for you, the primary care physician. Their mandate is to help you achieve meaningful use with the best EHR for your particular practice. But not all RECs are alike, and although if you use an REC you must use the one in your region, you do not have to use the EHR it is recommending.

If you prefer, you can do your own research and determine which EHR is best suited to your practice and provides the required functionality to attest to meaningful use. You can and should rely on EHR vendors to help you ascertain this information. And then you can go to your REC and say, "This is the EHR I want to use." The REC is required to help you in the same way as if you had chosen an EHR from its list.

Physicians exert enormous power in the EHR industry through their purchasing decisions. Consumer demand drives this industry. You call all the shots with the RECs, so you can concentrate on the important business of implementing the best EHR for your practice and then attesting to meaningful use, which is all the RECs really want for you anyway, and entirely how they get paid.

This article was originally posted at http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=745416&sk=&date=&pageID=6