To assist eligible providers, regional extension centers were funded to move practices from paper-based to EHR-based documentation, but there are other ways to accomplish the same result.
U.S. physicians who are eligible providers (EPs) will adopt electronic health records (EHR) in the next three to four years or face federal patient reimbursement penalties. To assist EPs, regional extension centers (RECs) were funded to move practices from paper-based to EHR-based documentation; but there are other ways to accomplish the same result, including independent EHR consultants and “do-it-yourself” approaches. This article contrasts these approaches and looks at how the change in the federal approach has affected EHR adoption processes overall.
Be aware that RECs are not a homogeneous group of organizations, rather they vary a lot in their approach to the market, and so your local REC may be different than described here. According to a 2009 American Medical Association news article, 30 percent of EHRs are abandoned or uninstalled within two years after deployment. Recent estimates of uninstall rates are even higher.
For EHR developers, RECs recall the DOQ-IT Quality Improvement Organization (QIO) initiative of the Bush Administration. RECs were part of 2009's $34 billion American Recovery and Reinvestment Act (ARRA). ARRA empowered the Office of the National Coordinator (ONC) to establish RECs to assist thousands of EPs (collectively 100,000) to become meaningful users (MUs) of government-approved EHRs within three years. It's the most expensive government EHR-adoption program ever, so the stakes are high.
Washington's actions in threatening to reduce Centers for Medicare & Medicaid Services (CMS) reimbursements to physicians are creating anger. Doctors who see Medicare and Medicaid patients are becoming extremely frustrated with these antics. Taxpayers are afraid of spending so much money and making a costly mistake that will harm America's senior citizens and 33 million newly insured under the healthcare reform legislation just passed.
In the July issue of Health Management Technology, the impact of 16 months of MU definition delays was discussed. Now that MU is finally defined, market confusion may abate, coaxing some EPs back into the market. REC revenues depend on that, but RECs face competition from independent EHR consultants. How can EPs decide who will guide them?
Uncle Sam is giving RECs about $5,000 to help EPs adopt EHRs. Here's how it works: When a REC enrolls an EP it receives around $1,666, the first of three ONC grant payments. The second payment is received after an EHR is deployed and provides computerized provider order entry (CPOE) functions, electronically receiving lab and other test results and implementing electronic prescribing (e-Rx). The REC receives the third payment after the EP demonstrates and is certified as achieving MU for 90 days.
Each REC has the same payment deal with the ONC. Does this REC payment schedule distort the EHR planning process by prematurely accelerating EHR adoption and deployment before other essential tasks are performed? Should an EP choose their REC or an independent EHR consultant to help them adopt an EHR?
Independent EHR consultants (ICs) lay much groundwork before selecting EHR products. Product selection is not among their first priorities, perhaps because ICs are not locked into the government's three-payment scheme. ICs determine practice readiness, assess networking infrastructure, determine EP user-interface preferences, determine facility renovation requirements and guide EPs to consider if patients should enter their own data via in-office kiosks or Web portals.
ICs discuss the server location (in-office versus over the Internet), including remediation strategies for various choices during hardware failures, communication or power interruptions. ICs help EPs document their specific work-flow-related issues and how the EHR fits into overall office work flow, which transcends EHR work flow. ICs help EPs understand EHRs with user-accessible, work-flow engine versus EHRs that impose static work flow. ICs show EPs how to access work-flow fit during EHR product demos and how to conduct site visits to determine product satisfaction, ease of use, vendor support quality and training required. ICs help EPs decide if using an EHR with an integrated practice-management system (PMS) is a viable first step for their practice versus keeping their current PMS.
This preliminary groundwork is usually completed before candidate EHR products are evaluated, since it bears on EHR functionality needed. That may not be the case with most RECs, particularly if they are in need of that second ONC payment, which requires a deployed and functioning EHR.
For EP do-it-yourselfers, follow processes outlined in books such as “Successfully Choosing Your EMR: 15 Crucial Decisions,” by MSP (Wiley Press); or “Electronic Health Records,” by Margret Amatayakul. A little time and $120 is far less expensive than using an IC, or REC-referred consultant. Such differences in planning approaches have real implications on EP satisfaction with their deployed EHR.
Of the more than 600 EHR products actually available, RECs may have started with 160 or so with Certification Commission for Health Information Technology (CCHIT) certification and have received request-for-qualification (RFQ) responses from only a subset of these. They then typically select three to 10 EHRs to offer to EPs. Many ICs can recommend two or three times that number. EPs can use the Web-based MSP EHR Selector to do their EHR product research and comparisons, just as many ICs do. Some RECs now also offer the same tool to their EPs, others don't. Check with your particular REC.
What are RECs looking for?
According to Monica Arrowsmith of I-HITEC, in Indiana, EHRs were prequalified that included integrated practice-management-system (PMS) solutions, but many EPs won't need (or be able to afford) these. Web-based, software-as-a-service EHRs are preferred, perhaps because this REC believes in-office solutions are too difficult for smaller EPs to manage. The Louisiana REC, however, didn't rule out in-office EHR solutions (according to a recorded July 2 RFQ clarification call). So these two RECs have inconsistent approaches based on their opinions of what every EP will need in an EHR. Here are other choices the Indiana REC made for its EPs: integrated EHR+PMS solutions; significant installed base in Indiana; minimum training required; each EHR covers all primary care specialties (not just a single one like pediatrics); and meets current CCHIT certification.
While generally good choices, they nonetheless eliminate many viable EHR products that would be good fits for individual EPs. Some larger EPs can manage in-office EHRs, and with an in-office approach, the EP controls whether to upgrade to the newest EHR-software version. With an Internet-based EHR, the EP has no choice but to accept the newest version, in most cases. If a practice can't replace its current PMS now, why should it only consider more expensive EHRs with integrated PMS? If a practice wants its EHR to interface with its current PMS, but none of the REC-approved EHRs do, what then? How are length of training and ease of use related? Do any prequalified EHRs include user-accessible work-flow customization? If an Internet EHR is chosen, local installed base is less important; everyone can operate their Web browser. Ask consultants for a Gantt chart. Note the sequence of the tasks and ask the consultant to explain them to you. Ask also for a list of EHR products their clients have adopted, and then determine if they are recommending a cross-section of EHR solutions, or consistently picking only a few vendors.
The ONC has deferred EHR qualification to RECs, who issue RFQs. The Rhode Island RFQ was 40 pages long online, but also required printing in triplicate and mailed submission. That's 120 pages of required documentation — a tedious, non-green, time-consuming process instituted by an organization charged with showing EPs how to live without paper in their practice. Multiply that by 59 other RECs, all using different forms, different qualification questions, issuing RFQs around the same time and you realize what EHR developers (and other EP subcontractors) went through to qualify EHRs that already had CCHIT certification. EHR developers found completing all these RFQs a daunting, time-consuming and exhausting task. Many with excellent products simply could not participate and were thus overlooked. Reviewing EHR submissions received took a lot of time; ultimately, a few EHR products qualified, but based on what recognized standard? Why are 60 RECs qualifying EHR developers individually in the first place? Isn't that exactly what the government created CCHIT to do?
What is CCHIT certification good for?
President Bush created the ONC and the ONC created CCHIT to accelerate the adoption of EHRs. CCHIT felt having a minimum common denominator for EHR functionality would do that. In fact, it didn't, but its certification was required for liability premium discounts, Stark Safe Harbor exceptions and other incentives, so 160 EHR developers paid $28K to have their EHRs CCHIT certified. They paid another $75-90K to add features that were not essential to the market specialty, but CCHIT nonetheless considered minimum for an EHR.
Whatever you think of CCHIT, it was at least one, totally transparent standard that included rigid compliance testing. In 2009, Obama's Congress undermined CCHIT certification by having 60 RECs pre-qualifying CCHIT-certified EHR products without validation, based on inconsistent, opinion-based requirements and a cumbersome, expensive process that EHR developers (who didn't wish to be excluded from selling to 100,000 EPs), were forced to accommodate.
Why Congress felt that 60 not-for-profit organizations, some with little EHR consulting experience, were competent to qualify EHR products for the U.S. market is a mystery. In N.J., NJIT is the REC. It's a wonderful university with computer engineering courses, but does it have extensive EHR consulting experience? So on what basis is NJIT more qualified than CCHIT to determine for all N.J. EPs what EHR products will be offered? No matter, CCHIT's certification was undermined.
Alisa Ray, new executive director of CCHIT (following Mark Leavitt's sudden retirement), hastens to point out that CCHIT can do the new MU certification as part of the same fee it charges for its CCHIT certification; but that doesn't change the fact that many EHR developers feel betrayed by both CCHIT and Uncle Sam, and EHR vendor support of CCHIT is waning, as shown in the MU certification chart.
By dumping CCHIT, Democratic legislators delayed EHR adoption further and distorted the EHR market towards a small subset of larger EHR developers. But what about the many smaller and emerging EHR companies that HITECH has hurt? If they fail, it will not be because they lacked competitive products, but simply because Democrats have legislated an expensive process too burdensome for smaller EHR suppliers to comply with, even those with CCHIT certification. Ask EHR developers not prequalified by RECs how they feel about Congress, 15 months of delays in clarifying meaningful use and 60 REC RFQs to be completed so they can sell their products to 100,000 EPs that have been driven to the sidelines due to confusion about federal reimbursement requirements. We can't print the responses here.
Why Congress intentionally moved procurement of $34 billion for EHR technology outside normal government purchasing regulations, circumventing GSA and federal acquisition regulations, is a matter of speculation. Some cynical observers see the REC process as a vehicle for political paybacks.
The EHR qualification process has no overall feature matrix summarizing requirements made by all 60 RECs, nor any explanation of how individual criteria were weighted in picking the qualified from the non-qualified EHR products. The entire process is hidden, in spite of the published RFQs. Can EPs trust that their REC has made the best choices for them? It's a very large expenditure for 100,000 EPs at $44K to $64K per EP, if they all adopt and achieve MU status.
The right EHR for you
EPs can procure and deploy EHRs from a non-prequalified EHR developer, but doing so puts them on their own. Some EPs will be reluctant to do that, and want to just be told which EHR to buy. If you are among these EPs, the REC approach is probably best. If you want to be more involved because you have to live with the results, use an alternative method to evaluate viable alternative EHR solutions. The more involvement EPs have in their own EHR planning, the more likely they are to be committed to making the EHR work. No IC or REC can make the right EHR decisions for an EP.
There is office work-flow variation across 1,000 to 2,000 different EPs. EPs must ask, “Can my total office work flow be easily accommodated by the EMR I am considering?” Without a RFQ requirements crosswalk, no one can determine what coverage of work-flow issues was included across the universe of REC RFQs.
RECs differ in approach; some are empowering their EPs to decide what EHR best meets their needs and won't negatively impact work flow after deployment. Kudos to those RECs; they take seriously the ONC mandate: “… to offer technical assistance, guidance and information on best practices to support and accelerate health care providers' efforts to become meaningful users of electronic health records (EHRs).” The REC program is also intended to “establish a national health information technology research center, funded separately, to gather relevant information on effective practices and help the regional centers collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use and provider support.” EPs need to educate themselves in order to do this, and some EPs feel that takes too much time and effort.
The national implications of EHRs with poor work flow are profound. If an EP using paper documentation is currently seeing 30-35 patients a day in three to four exam rooms, and that drops to 25-30 per day using an EHR, what will the national loss of productivity mean to patient care delivery in this country when multiplied by up to 100,000 EPs? If EPs can't see their current patients as quickly after adopting an EHR, how will they find the capacity to see any of the 33 million newly insured patients under healthcare reform legislation?
The implication of improving versus crippling EP productivity is therefore very important when scaled to the national level. Every EHR has some impact on productivity. The time to evaluate work flow impact on productivity is before the EHR is chosen, not after its deployed. It will be a couple years before we know what effect the REC process has collectively had on EHRs.
EHR adoption is paradigm change — from an unstructured, page-oriented, paper approach, to a highly granular, observation-structured, database-driven approach. Pages are replaced by computer screens, which also replace reports. Organization of information flow is critical, and different users have different presentation needs. Charting in more detail is forced. Data field choices are therefore directly related to speed of entry and ease of use. It's a big change. And EPs need to ponder it and not be rushed by anyone.
EPs should be wary of accelerated adoption processes, or REC/EHR vendor relationships that seem a bit too cozy. Whether EPs choose their own EHR or go through a REC or an IC, they need to keep their eyes open wide and ask a lot of questions. Failure will be expensive. EPs only win if they choose an EHR that is cost effective, inexpensive to maintain and at least work-flow neutral.
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About the authors and Medical Strategic Planning
Formerly manager of market research for Siemens Corporation's electro-medical division, Arthur Gasch has spoken extensively on EMRs. He was contributing editor for Biomedical Business & Technology newsletter from 1992 to 1996 and is publisher of Industry Alert, a publication on emerging technologies to the U.S. hospital market. Gasch is co-author of “Successfully Choosing Your EMR: 15 Crucial Decisions” and in 1992 founded Medical Strategic Planning (MSP), a New Jersey-based medical market research firm offering the MSP EHR Selector as the only interactive, Web-based, critically vetted EMR product comparison tool that includes MU, HIPAA and PQRI criteria and the latest KLAS Research EMR product-satisfaction scores. Learn more about MSP at www.medsp.com. Art can be reached at firstname.lastname@example.org.
Bill Andrew was the first HIMSS Lifetime Member, executive VP of the MSP EHR business unit, founder of Andrew & Associates, and creator of the EMR Survey, which became the MSP/Andrew EMR Benchmark, the most comprehensive EMR product compendium of the North American EMR market. Andrew established Andrew & Associates to provide EMR consulting services to the industry, prior to joining MSP. The EMR Survey was established by Andrew in collaboration with Dr. Richard Dick, Ph.D., and Dr. Robert Bruegel, Ph.D. Andrew also established the first industry-wide survey on EMR work-flow management systems, data that has now been incorporated into the MSP/Andrew EMR Benchmark. Bill can be reached at email@example.com.