Yesterday, HHS’s ONC announced the final two Regional Extension Centers (RECs), one in California and the other for the state of New Hampshire. Much like the Land Grant College Program and the much smaller Sea Grant Program, the HHS RECs have been established to assist in the appropriate adoption and use of technology, in this case EHRs. Since the passage of the HITECH Act, there has been concern that harried physicians in small practices will struggle to take advantage of the HITECH Act and the incentives therein for the adoption and meaningful use of certified EHRs. (Geez that’s a mouthful). State RECs, staffed with IT specialists will be charged with venturing forth into the countryside and cities to help physicians adopt those EHRs and get those HITECH incentive payments.
Chilmark has some very strong reservations about the success of the REC program. Well, we’ll go even farther to say that it is destined to go over the proverbial bridge, plunging into the abyss of failed federal/state programs.
Now the folks at Software Advice have outlined 5 reasons why they see the REC as “RECkless” and they have, for the most part nailed it. Where Chilmark differs is more on emphasis, where we focus on three key points:
1) The RECs will not be able to staff themselves with strong HIT talent. There is a gold rush happening right now with software vendors, consultants and other HIT service providers flat-out. Chilmark sees this first-hand in our daily conversations with numerous HIT companies, with many expressing that they are challenged to find good talent. So, if the private sector, which certainly pays far better than the public sector, is having difficulty getting talent, RECs will struggle even more. Which leads to the question: How competent will these REC advisors actually be in the field in assisting physicians in adopting best practices for HIT deployment and use? Yup, doesn’t look too pretty from this vantage point.
2) RECs artificially limit the market for EHR solutions. It would be a Herculean task to ask RECs to provide support for all 300 or so EHRs now in the market. To overcome this, RECs are picking just a few EHRs that they will take to market in their state. For example, Massachusetts has picked 10 preferred vendors: AllScripts, athenahealth, eClinicalWorks, eMD, Epic, GE, Greenway, MedPlus, NextGen and Sage. Vermont has picked only three, AllScripts, athenahealth and Fletcher Allen. And then we have the great state of Virginia with also a measly three preferred vendors, AllScripts, athenahealth and MDland. Sure, AllScripts is a national brand and known for their ambulatory solution, but so is eClinicalWorks that has been on a tear in the ambulatory market. And athenahealth, only recently released a version of athenaclinicals that is robust enough for a small to mid-size practices. So what about all the other EHRs, some quite capable in meeting a physician’s requirements? Will they fall to the wayside simply because they were not politically savvy enough to get on-board with these RECs? Talk about warping the free market upon which this country was founded. Quite sure that Adam Smith is rolling over in his grave on this one.
3) Time or lack thereof. As part of the Stimulus Bill (ARRA), which was more about putting people back to work, the HITECH Act has a very aggressive schedule, so aggressive that it is likely that much of the federal largesse now beginning to be poured into this still immature market will be wasted (our guess: x > 35%). It takes time to recruit talent. It takes time to train and deploy them effectively. The time horizons for physician adoption of EHRs to capitalize on the incentives are ridiculously short. Add all of this together and it’s not a pretty picture. This is not the fault of any government agency and the staff therein who are trying to do the best job they know how – no, they were just dealt a very difficult, if not un-winning, hand.
Unfortunately, the train has already left the tracks on this one and all we can do is sit-back and watch the inevitable. But along the way towards that final plunge over the bridge, Chilmark does sincerely hope that in some small way these RECs will indeed have some impact on the effective adoption, deployment and use of EHRs by clinicians as even a little is better than where we are today.
John,
I am a practicing family doctor here in Massachusetts, as well as Medical Director of Informatics for a community hospital system that has 100 physicians using EHRs, so I have become quite familiar with the meaningful use criteria. My strong opinion is that the MU criteria are too complicated for the vast majority of solo docs or small practices to figure out and deal with on their own. They need help, and I think the RECs are their best bet to receive that help.
I have a more optimistic view of the RECs, as I see their role mostly as that of a matchmaker between a small physician practice and an EHR vendor and/or an IOO.
I am not sure how much strong IT talent the REC needs to employ, as long as they can put together a group of skilled IT advisors like has been done here in Massachusetts. I think the IOO’s are the folks who will be in the field assisting physicians in implementing and optimizing and adopting best practices.
And while I agree the deicision by VT and VA to only offer 3 choices of EHR vendors seems too restrictive, the choice between 10 EHRs being offered in MA seems reasonable to me. The process was open to all vendors to apply, so we may not be seeing artificial market limitation, but rather self-selection by EHR vendors who aren’t that interested in the small practice market or don’t want the additional oversight the REC promises to have (I am curious how many vendors applied and were rejected).
But I don’t think we want 300 EHRs to pick from, as there is interesting data that giving a person more choices can be paralyzing (I love Barry Schwartz’s TED talk on the Paradox of Choice http://bit.ly/u0eOZ), and I certainly know physicians who have been overwhelmed by all the potential EHR choices. I think having the REC to help hold vendors accountable is a good thing, as we all know too many docs who have had EHR horror stories.
I do completely agree with you that time is not on the side of the RECs. They have been given a very challenging timeline to recruit physicians. And the doctors they are targeting are busy and difficult to reach out to. But if not the RECs, who else will reach out to these small physician practices?
Another challenge I see is convincing the physicians of the value of the RECs and getting them to pay to join. A lot of physicians aren’t used to hiring outside consultants to help them, and they may think they (or their cousin who is “good with computers”) can sort all this out on their own without joining the REC. And many docs will figure it out, because they are resourceful and smart and hard-working. But I think joining the REC and receiving help from the IOO can make it so much easier. I see the REC as meaningful use insurance.
I am particularly enthusiastic about the REC for the doctors who have already invested in EHR’s, as I feel these docs need help from an IOO who understands process improvement and can make sure that physicians have the certified version of their EHR software and that they are checking all the right boxes instead of just free texting. And I want physicians to get help so that ultimately they are using the EHR to engage their patients and to meaningfully improve their care.
-Michael Coffey, MD
Michael,
Thanks for your very thoughtful and thorough comments from one who is literally on the front-lines in the adoption and deployment of EHRs. You make several valid points and reference the work in MA wherein, at least in this state, there is some choice available to physicians seeking an ambulatory EHR. Agreed, helping physicians in the decision process by having RECs vet and choose a subset of vendors to support in a given state has its merits but at what expense? Will we limit innovation choosing only those that have the resources and/or political savvy to jump through the hoops to become a preferred vendor? What about those vendors who are now looking to enter the market with possibly a complete new model, e.g., Epocrates who is planning to introduce an mobile EHR app in the near future? Are they now shut-out out of the market? This is a very real possibility and one that does not serve the market. In our quick review of several REC websites, Chilmark did not find any that had a process to add additional EHRs. Maybe we did not look deep enough to find such, but have a funny feeling such does not exist.
As you point out, RECs could serve the very real role of assisting physician practices with simply understanding what are the meaningful use requirements, what physicians will be required to report to obtain those incentive payments and even generic best practices (not vendor specific) on selecting and deploying a certified EHR. For example, trained REC employees could advise physician practices on the trade-offs between going with an SaaS model vs a traditional client-server model for an EHR. Maybe that is enough for these RECs to accomplish and asking more from them, i.e., choosing vendors, is a path that RECs should never had ventured down.
Michael makes excellent points.
It might also help to look at another precedent way back in American history: the railroads. The federal government chose a small number of railroads to serve a number of critical routes for obvious practical reasons, and naturally the politically-connected players won. It made a few people filthy rich, but any inefficiencies it created (local monopolies or near monopolies) were far outweighed by the massive advantages in moving people and goods. Any analogy breaks down at a certain point, but my point is that innovation and public benefit are not linear functions of the number of competitors. You could look to the VA or the space program for more recent examples. How government regulates and pushes improvements will be key.
Except railroads represented an advancement over the status quo, and EMRs in general do not. As Michael said, the goal with an EMR is to check the right boxes, not enter free text. Therein lies one of the problems with EMRs to date. Discreet data may be great for public health, but it is dangerous for individual patients. RECs have been charged with a disruptive and unhelpful task. Fortunately, none of the primary care docs I know have heard anything about them.