EXECUTIVE SUMMARY
Regional extension centers (RECs) are now mostly in the early stages of planning their organizations and facilitating physician adoption of electronic health records (EHRs). However, two New York RECs are frontrunners in this space and use collaboration to conquer the complexities of meaningful use.
A recent survey from the eHealth Initiative (Washington, D.C.), a non-profit whose mission is improving quality and safety in healthcare through information technology, took the temperature of today's regional extension centers (RECs), and found the climate to be rather tepid. Not only were many of the RECs still in early planning phases, but progress was slow to transition letters of commitment by providers into signed contracts. The picture, however, is not altogether bleak. Two outliers in New York are leading the pack, with a deep sense of collaboration and a focused purpose key in their success.
A NEW YORK ‘STATE’ OF REC
First, a little background on the 60 RECs across the country: Funded under the Health Information Technology for Economic and Clinical Health (HITECH) Act, RECs have a mandate to support 100,000 primary care physicians in moving toward electronic health record (EHR) adoption, and ultimately meaningful use, of those EHRs. It is expected that these RECs will all be fully functional by mid-2010 and largely self-sustaining by the middle of 2012. Every two years, a Health and Human Services-appointed panel of private experts will evaluate the RECs' performance to judge if continued support is merited.
The number of RECs to be developed in any particular state is naturally determined by population. For reference, California and Texas have three and four RECs, respectively. The Empire State in comparison only has two regional extension centers: the NYC Regional Electronic Adoption Center for Health (REACH), a collaboration between the New York City Health Department and the Fund for Public Health in New York, which covers New York City; and the New York eHealth Collaborative (NYeC), a public-private partnership with the New York State Department of Health and other entities, which covers the rest of New York State.
NYC REACH formed in early 2010, and grew from the Primary Care Information Project (PCIP), which oversees NYC REACH. The PCIP was a New York City mayoral initiative through the NYC Department of Health and Mental Hygiene in 2005 that was tasked with better serving disadvantaged communities and uninsured patients by closing the technology gap. Since then, NYC REACH has grown to a 60-person group with a budget of $60 million in city, state, federal, and private funds. Some of NYC REACH goals this year include extending EHRs to 2,500 primary care providers, providing a million patients with self-management tools (e.g. patient portals), and helping physicians achieve Patient-Centered Medical Home accreditation.
NYeC (pronounced “nice”) started in late 2006 with support from the New York State Department of Health and other state entities, including regional health information organizations (RHIOs), health information exchanges (HIEs), medical societies, and other healthcare stakeholders. In late 2009 NYeC received REC status, and since then has established a staff of close to 60 people including 10 local-level extension agents throughout the state. “Rather than us developing people that we then put on trains, planes, and automobiles to get out there, we convened a lot of stakeholders throughout the state to assist in the process,” says NYeC executive director Paul Wilder.
Wilder convenes biweekly meetings with extension agents to discuss grant-level initiatives, tools agents need to employ, and services to push out to providers. He's currently in the process of organizing his staff and developing workgroups like an outreach collaboration group to recruit and educate providers about EHRs and another one to deploy services.
IT TAKES TWO
The ONC grant requires RECs to set a minimum commitment of providers to achieve EHR adoption, which is a minimum of 20 percent of the primary care providers in the geographic area. NYC REACH's commitment is to get 4,543 providers using EHRs, while NYeC's goal is 5,107 providers. A casual, yet telling exchange between Amanda Parsons, M.D., assistant commissioner of the NYC Health Department's PCIP, and NYeC's Wilder, explains the origin of New York's two RECs, and also gives a glimpse of their collaborative spirit and playful rivalry: “I tried to convince the state to have at least three[RECs], but the state at the time thought that because of the way that funding goes, New York State would only get two,” says Parsons. “So we [PCIP] said ‘no one can do New York City better than us, so we're going to apply,’ and then they decided to roll up New York State into one organization.”
“[We thought] maybe we could have done two groupings of 2,500 [providers] to get to the minimum grant level that we could commit to organizationally, maybe a downstate and an upstate [REC], or something to that effect, but we didn't believe we'd have more than two accepted,” Wilder says. “So we ran [with a New York State REC] and with New York City since the organization existed and there was no reason to encroach on them in any way shape or form.”
“And we didn't give you guys a choice [laughs],” Parson interjects.
“We could have if we wanted to, [laughs] but likewise, New York City was smart enough not to do Long Island,” jokes Wilder.
COLLABORATION LOCALLY AND NATIONALLY
A cooperative spirit is not only evident in the casual banter between Parsons and Wilder, but in their organizational practices. Not only are both regional extension centers' headquarters about 10 blocks away from each other in the Manhattan neighborhood of Tribeca; the two organizations meet biweekly to share best practices and lessons learned. Parsons notes that the overall model of a regional extension center is inherently collaborative, especially with the formation of the Health Information Technology Research Center (HITRC), a virtual community of the nation's RECs.
According to Parsons, HITRC allows RECs to upload best practices and other helpful documents to share with everyone in the network. “It's a grant requirement that you work with other extension centers,” says Parsons. “It's really nice because it gives everyone an incentive to work together and learn together and share tools.” HITRC also facilitates workgroups called communities of practice (COP) that have regular calls to share findings around topics like vendor selection, meaningful use, outreach and education, and security.
VENDOR SELECTION
Part of the process of getting providers to use electronic medical records is selecting the proper vendor partners for a REC's community needs. NYC REACH originally had a singular contract with eClinicalWorks (Westborough, Mass), but because of grant requirements, the organization needed to add other vendors to the mix. So, then came the request for information (RFI) process, which NYC REACH did jointly with NYeC. “We worked together with New York State because we thought we could leverage some economies of scale and group purchasing power; and frankly, to sort through what's essentially a field peppered with about 200 different electronic medical record vendors takes a lot of brain power,” Parsons says.
The 25-member due diligence team proceeded with a vendor selection process that Parsons remembers as challenging, mostly because the EHR certification bodies had not been named yet, nor had the final meaningful use rule been released. Both organizations' chief goal was a clinical information system that would enable their providers to achieve the meaningful use requirements. One of the decisions made in the selection process was to seek out an integrated system, as opposed to a piecemeal solution. The targeted providers didn't need, or have the money to buy, separate EHR, practice management, portal, e-prescribing, and lab components to be interfaced.
Other vendor criteria included having at least 1,000 installations nationally, CCHIT-certification, HIPPA-compliance, and several others. “It was a behemoth effort because you have to evaluate them from a technical perspective, financial perspective, ability to provide services, and you have to look at their pricing models and experience,” says Parsons. “Most importantly you have to select a record that passes the certification test for meaningful use.”
The team received 25 responses, and eventually selected 10 to do vendor demonstrations. In April 2010, the RECs announced their vendor partners. NYC REACH created two tiers: the first group included eClinicalWorks, Greenway (Carrollton, Ga.), MDLand (New York, N.Y.), which NYC REACH offers both implementation support, as well as services to achieve meaningful use criteria. The second tier of vendors included NextGen (Horsham, Pa.), MedLink International (Ronkonkoma, N.Y.), athenahealth (Watertown, Mass.), and Eclipsys (Atlanta), which NYC REACH only provides meaningful use support for. NYeC ended up choosing five preferred EHR vendors: eClinicalWorks, Eclipsys, Greenway, NextGen, and Sage (Tampa, Fla.).
WHEN THE GRANTS DRY UP
In January, the ONC released a total of $643 million in federal funds to finance the nation's RECs. The funds are being administered for the next two years, and then the RECs will receive an additional $42 million in the subsequent two years. The thrust of the grant is to fund primary-care services, with an emphasis on individual and small group practices (fewer than 10 clinicians), as these groups have the lowest rates of adoption of EHR systems in the country. The New York RECs received similar grant amounts, with NYC REACH receiving $21.7 million and NYeC garnering $26.5 million. The grant is not direct, but milestone-driven, with $5,000 administered for each provider brought online. After the grant dries up, the REC is responsible to remain sustainable.
Like their close relative the HIE, RECs face similar challenges with sustainability and physician adoption. Besides these common obstacles, Wilder notes that interoperability within the larger framework of health information exchange within a community and on a national basis will be complex. Parsons' main frustration is that she wants more out of current technology like language translation software within the EHR, and linkage between now disparate systems-like for instance connecting modules like home care with the emergency department. Parsons is excited, however, about getting EHRs to the physician masses, so more advances can be made toward quality healthcare.
FOLLOW THE PURPLE LINE
The road ahead is a long one for RECs, with many RECs still miles away from meeting the grant provider requirements. NYC REACH so far has 815 providers connected toward its 4,543 provider goal (the organization has a total of 1,095 members, however only 815 of them count toward the grant). NYeC, which got a later start than its fellow REC, has 153 of its 5,107 targeted providers connected.
Wilder says that despite the hurdles RECs must face, organizations like his are extremely important in guiding providers on the right path toward meaningful use. His main focus is getting his members to stay the course. “One of the main colors for [NYeC] is purple, so we're saying ‘follow the purple line,’ [like the Fidelity's ‘follow the green line’ slogan],” he says. “There's many things along the way that can distract you from getting to meaningful use, and we're going to set out the line to keep you on course.”
NYeC recently held a series of one-day EHR summits in Rochester, Syracuse, and Tarrytown, to name a few, to spark dialogue around EHR adoption and spur participation. While the focus now is getting physicians outfitted with EHRs, down the line NYeC will offer services surrounding the future stages of meaningful use and medical home certification.
Parsons says that right now, NYC REACH is in the thick of understanding the nuts and bolts of meaningful use and gleaning the intricacies of implementation in individual practices and how best to get each one through its meaningful use journey. Her organization is in the process of developing several tools and digestive materials to describe the complexities of meaningful use. “The final rule is 864 pages, with no summary, so that makes it really hard for people to actually engage in the material; so they are incredibly reliant on summaries,” Parson says.
NYC REACH also has several events to clarify meaningful use and promote outreach. Besides webinars, the organization holds open houses where providers can meet with EHR and meaningful use specialists, integration and implementation staff, and providers who have implemented EHRs. NYC REACH also hosts specialized training sessions around a variety of topics like Patient Centered Medical Home, payment posting (electronic remittance advice), and patient portals.
Parsons trumpets extension centers as sources for unbiased advice and uses an apt metaphor of a personal trainer to summarize the role of the REC. “You're going to get more fit and lose more weight and push yourself more if you have a trainer,” she says. “So you want to figure out how to be the best trainer you can be, so that it makes no sense for them [providers] to not come to you.”
Healthcare Informatics 2010 November;27(11):37-41
