Strictly speaking, the nation's 62 federally designated health IT regional extension centers (REC) are signed up for a four-year run, during which they have been given the job of elevating the least-equipped and neediest of health care providers into the 21st century.
In practical terms, though, they have just two years to put EHR systems into the hands of primary care providers and get them to use the computer tools well enough to earn incentives under the HITECH Act. That's because 90 percent of the funding runs out after two years, and RECs have to demonstrate sufficient progress just to get the last 10 percent in the third and fourth years.
It gets even more time-stressed. Except for a relatively small grant for physician outreach and start-up activities, the federal money is meted out to a REC as its providers attain each of three milestones: they're enrolled in the REC program; the practice goes live on an EHR that enables them to meet meaningful use requirements; and they demonstrate that meaningful use. Think about the many months it will take to cover that kind of ground.
In short, it's now or never to gather the means to forge successful EHR use. And RECs are thinking fast. Their leaders are intently setting the stage for picking EHRs, amassing the personnel needed for the launch challenge and smoothing the way for results that could mean big paydays not only for their provider clients but for the RECs themselves.
Some experts say the tight timeline requires getting quickly to the installation and work redesign processes, where providers will either master whatever EHR they have selected or flounder while the federal incentives and the advantages of computerization pass them by.
"Vendor selection is a trivial activity relative to the complexity and level of effort it will take to get to meaningful use," says Jay Fisher, founder of Milwaukee-based C3 Partners, a consulting firm with a health care practice centered on meaningful use compliance.
But for REC clients who do not already have an EHR up and running"a vast majority"it's still the first hurdle. Plans for RECs to present vendors' products to clients vary by state but often have similar aims: evaluate vendors' EHR products; single out a subset of EHRs in order to be more expert in launching them; and drive down the price"whether by negotiating a group-purchase agreement, letting the market respond to transparently posted pricing, or something in between.
"Providers want a lot of choice; we want to bring a lot of expertise to the table," says Amanda Parsons, who directs the REC covering New York City that is supporting just three choices of EHR. "We think choice and expertise are actually inversely related"the more choice you have, the less expertise you're going to have as an extension center. And practically, the providers we serve need a lot of help."
Other RECs are willing to take all comers, regardless of the expertise challenge it represents. "All four Texas regional extension centers are vendor-agnostic"we will not be selecting vendors to support our physicians," says Kristin Jenkins, president of the Dallas-Fort Worth Hospital Council Education and Research Foundation, which holds the grant for the REC serving that metro area. "In our state, we want to be able to offer support and advice to our providers for any current electronic health record they use or for ones they want to consider."
Managing EHR selection
RECs nationwide are trying to zip through the evaluation of potential EHR products and set parameters for their technical support while recruiting the number of providers they're contracted to serve.
The four RECs formed to cover Texas, for instance, saved time and expense by conducting a joint vendor evaluation of nearly 70 products, says Jenkins. And the New York City REC"going by the acronym REACH"teamed up with the New York eCollabo-rative (NYeC), which operates the REC for the rest of the state, to conduct several rounds of show-and-tell sessions that eventually pared the list of EHR products they would support to single digits from more than 170 at the outset. The five that NYeC is supporting includes two of the three supported by REACH.
"The reason for the selection is the same [as for REACH]," says Paul Wilder, program director for the New York State REC, "it's to create a smaller set of things we need to know so we can create some focus and have some expertise"I don't think you can be an expert on everything, it's just not possible."
A handful of other RECs, including those covering Massachusetts, south Florida, Vermont, Virginia, Georgia and a Cincinnati-area region, had announced anywhere from three to 10 preferred vendor partners by mid-October.
While listing their preferred partners, several RECs were careful not to foreclose working with a wider range of EHR products, especially for practices that already had made and set-up a non-preferred choice.
"We really began this process from Day 1 by ensuring that we did not create a feeling as though we were somehow removing options from providers," said David Groves, executive director of Tri-State REC, which covers the Cincinnati area and sections of southern Ohio, northern Kentucky and southeastern Indiana. "What we'd like to do is present some well-considered options" that we've looked at ourselves as experts"that we think they should consider. But we're by no means suggesting that they should not consider others or have the freedom to work with others if they still want to work with us."
In states like New Mexico with low physician and total population, the notion of narrowing the numbers of vendors the RECs will support is not an issue. "The reality is, with only a few thousand physicians in our state, the number of vendors who will invest in serving our clinicians across a wide geographic area is limited," said Dr. Robert White, medical director of clinical informatics for LCF Research, which operates the state REC. "Most of our selection of vendor partners is determined by the vendors who are willing to work in our state and who have enough presence that physicians will have colleagues that they can talk to about their experience."
Approaches to price reduction
Despite the regional calibrations, it's clear how HITECH's federal managers view supply and demand for technical services.
One of the motivators for the HITECH Act's financial incentives was to remove the barrier of price for the many smallor medium-size medical groups that saw the purchase of EHR systems as unaffordable. Early on, the Office of the National Coordinator (ONC) encouraged the idea that RECs not only help these practices gain the available incentives but also weigh in at the front end as an agent of EHR price reduction.
In a technical-assistance call in August 2009, months before the ONC began to award REC contracts, its deputy national coordinator said extension centers should make use of their power to negotiate price breaks.
"We think that extension centers should do group purchasing for the providers," said Farzad Mostashari in answer to a questioner. "We think that there should be probably a smaller range of options for the extension center to really get familiar with offering support to them and to really have some leverage over the vendors."
A smattering of RECs is certainly going to try. Says Parsons of New York REACH: "I definitely felt that one of our goals was to drive the price down, particularly for primary-care providers because there's obviously a lot less profit margin [for primary care] to begin with." A vendor accepting a lower price could gain in other areas, such as sales to specialty groups in the same regions where many of their primary care colleagues have opted for that vendor's brand of EHR, Parson says.
