HIStalk Practice Interviews Jeffery Daigrepont

Jeffery Daigrepont is senior vice president of Coker Goup.

Give me some background on Coker Group, as well as your background.

We’re very much a traditional consulting firm. We have two segments. One is more operations in nature, where it deals with a lot of strategy work for hospitals and physician practices. Then we have a technology division, which I head up, which is strictly focused on IT strategies.

Where we’re a little bit unique is we do not have any financial ties with any vendor. We’re 100% non-biased and we work with a lot of folks, largely on the procurement, but also implementation. Believe it or not, about 30% of our projects are removing failed EHR systems, or going back in and reinvigorating EHR systems. That’s kind of it in a nutshell.

How long have you been with the company?

I’ve been with them ten years.

How do you see healthcare reform and ARRA complimenting one another? Or, do you think they actually conflict with one another?

I believe most doctors see reform — at least in the way it was passed recently — as a negative thing, with ARRA already being passed. I believe in order to survive they’re going to have to build better mousetraps, which means that to offset a lot of the reductions or the need to be expected to see more patients that’s now going to be covered, doctors are going to have to become more efficient if they’re going to survive.

Obviously, for those of us in the industry, it’s probably going to help us because we would be available to assist those and become more efficient. While some doctors see reform as negative, I also think now that it’s becoming passed, there’s a little bit of a sigh of relief. I’m not sure, but I’m wondering if now people will start moving on and making decisions. I think for a long period of time people were kind of putting major decisions off waiting to see exactly what it was going to look like and how they were going to be affected by it.

So are you seeing an uptick in practices moving forward with adoption?

I will say that when ARRA first came out, there was a lot of uptick in being intrigued and renewed interest. The market was kind of reinvigorated, so conferences saw an increase in attendance. I saw a huge uptick in doing interviews, speaking, presenting. A lot more people were coming to attend lectures on vendor selection and things like that. The market was upticked, but what I didn’t see a spike — I didn’t necessarily see a spike in the actual execution of contracts. There was a lot of interest whirling, but I think everybody was putting off the actual signing of the contracts.

Now, what was interesting; this week alone, I’ve seen a pretty considerable increase in past clients that were either on the fence or waiting to do something  that said, “OK, we’re ready to begin thinking real serious about this, and ready to start moving forward.” I don’t know what that percentage is. It may just be a fluke, but I do think many people have delayed major decisions until they saw exactly what was going to happen.

What impact do you think the RECs will have on the industry?

That’s a good question. First off, they have to be financially sustainable. Really, the only value that I see, at least on the surface, is to assist with implementation. So on one hand, that’s a pretty good source of revenue for the vendor. The vendor has to decide how much of that they really want to share with the Regional Extension Center, and whether or not there is enough room.

Then, once you do the implementation, what other tricks do you have? I mean, the vendors at least have recurring revenue for annual maintenance and support, and whatnot, so they can be sustainable. We do implementation and our clients are like, “How soon can you get here? How soon can you get it done?” They do not want people camping out on their payroll for an indefinite amount of time.

The other thing that I’m concerned about is whether or not there’s opportunity for conflict of interest. Let’s say Vendor A has a larger margin and is willing to share more in that margin or give up portions of the services that would ordinarily be done by the vendor, or through other strategic relationships — so hey, we’ll tilt business your way to the REC. Does that then induce more referrals or more friendliness from the Regional Extension Center to that particular vendor that wants to share more of their revenue, versus ones that might price their services a lot leaner and won’t have as much margin to share with these folks?

Then you also have the question of subject matter expertise, as to how deep will the vendor go? Because at the end of the day, the vendor’s name and credibility will be on the line. I know from doing a lot of project management and implementation work, there’s always a fine line between “I recommended this vendor,” and then I show up and do implementation services. If you screw up the implementation services, you can easily get upside down with both the vendor and the health system. Then who’s accountable?

One of the things you see vendors having to do all the time is go back in and redo stuff because, “Hey, I got bad advice. The trainer was a bonehead. This was just a total screw up.” The vendor has the value of the long-term relationship, so they’ll usually suck it up and go back in there and redo it. If one of these Regional Extension employees go in and they muck it up, who covers the note for them to come back in and do it a second time? I don’t know, contractually, who’s made accountable either.

I think the best model that I would think that could play out — and I don’t know how deep RECs would want to go, but every project has vendor-side responsibility and client side responsibilities. I think one of the big areas of need right now is client-side responsibilities, because they don’t have good project managers/leaders. So, the Regional Extension Center could play the role of the advocate for the clients, versus playing the role of the vendor. They’re going to have to decide if they’re going to be the client’s advocate, or they’re going to be the vendor’s go-to resource for delivering the services. You really can’t be both.

Obviously, because the RECs can’t be experts at every last software, they’re going to narrow down their preferred vendor list. What do you think is going to happen to those companies that don’t make that short list?

That’s what I was saying. I think if you’re forced to create a business model where you have to be financially sustainable, then human nature’s going to dictate that those Regional Extension Centers’ preferred vendors are likely going to be those that have the most opportunity.

I’ll give you a real good example. A lot of the little vendors, Web-based ASP vendors, are very light and nimble. They’ve got their implementation down to a couple days and they’re usually attracting physicians that really don’t want a lot of heavy implementation. Just keep it short and sweet. A lot of tools built, baked into the product so the product can self-customize and whatnot. When one of our clients goes that route, and we’re perfectly OK with it, there’s less opportunity for us to provide additional services.

Whereas, if they buy a NextGen, an Allscripts, if they buy an Epic, we’re in there for the next five years. It’s that heavy of a system. So, if I was building a Regional Extension Center and I need recurring, sustainable revenue, I’m naturally looking at a system that might be a little bit more self-serving. That gives me the opportunity to provide more services versus a light vendor.

So, I do think it’s going to hurt the smaller business that have been innovative, and trying to get their products installed in a way that doesn’t require a whole army of workforce.

I know you’ve worked with a number of hospitals to help them align with physicians. What are some creative ways for hospitals to do this?

I think that’s a great model, because many of the hospitals can subsidize a good portion of the cost, and usually care is a local thing. So when they can collaborate and become clinically integrated, there’s a lot of value. I think, conceptually, it’s a model that saves all the stakeholders a lot of money, and I also think it improves the interaction between the hospital and the physician, as well as with the patient.

The challenge with the model, almost always is politics — control of data and boundaries. If a hospital wants to buy Allscripts and then distribute it to their medical staff, Allscripts will continue to sell directly to that medical staff as well. You really have to be proactive in getting an understanding with your vendor that you are going to take their HIT system to market; and rather than unintentionally competing with your own vendor, work out more of a collaboration strategy where they help promote it so there’s not that market conflict.

Now some vendors like Epic, for example, have what they call their “hub strategy” and they’re actually teaching their hospitals and consulting with their hospitals on how to deliver Epic to the community. Epic doesn’t want to fool with small practices, but they’re more than willing to help prop up their hospitals to do it.

The ones that really do it right — Sentara Health System is a good example — where they really kind of commercialized their IT services. They even branded it with its own name. It’s called eCare. Well, eCare’s Epic, and the hospital, Sentara. But if it appears to be something kind of unique and not just the hospital giving me an EHR system or sharing it, it tends to play out a little better.

Also, another good structure, or the governance structure, is to include a lot of stakeholders or different members of the party you’re governing. Because you’re dealing with things that typically a hospital doesn’t have to address, they’re on one hand trying to stay a hospital, but they’re also becoming a vendor.

I’ve seen cases where the hospital gives an EMR system to a practice and that practice implodes. Well, the two doctors now don’t get along in the practice, and they’re both fighting over who owns the records. The hospital’s caught in the middle, so you’ve really got to work out a good service level agreement between your hospital and your medical staff or you could really get into some very uncomfortable situations.

What would you say some of the biggest mistakes practices make in the EMR selection and implementation process?

Probably the biggest one — and it’s really, more often than not, the practice’s own fault — they didn’t realize the magnitude and the commitment that was going to be necessary to be successful. Sometimes they just have buyer’s remorse, but it’s a good product, it works fine. But the practice didn’t realize that there was going to be a pretty big commitment.

Then, the second thing that’s probably just as common is a lot of times they just flat out bought a defective product or something that was not going to work at the point of care. It looked good in the demo; the vendor made a lot of promises. But at the end, it started to not perform as promised or as expected. Then people get discouraged and frustrated.

I would say the third mistake is contractually. A lot of those two things I just described could really be avoided if people would take the extra time to create a statement of work, or to develop terms and conditions tied to the goals and objectives of the project. Everybody’s aligned around the same outcome, so you can set up your payments with the vendor to be tied to outcomes.

I always compared it to building a house. You would never pay the roofer before you pay the foundation guy. You do it based on stages and phases. With each phase being successfully completed, you move onto the next phase and you structure your contract based around successful completion. You have a lot of testing, and build and validation built in to that, so that way you’re not just kind of going on blind faith alone.

Do any vendors come to mind in the ambulatory care space that you think are consistently doing things right in terms of product, implementation, and support?

The KLAS surveys tend to track that around customer service. I look at vendors like Allscripts that have unbelievable market savvy, but they have five EMR systems and four practice management systems. At the point of sale they’re talking about a MyWay product, a professional product, an Enterprise product. I think that’s what the hard lesson is. We’ll look back in five years and what they’ll ultimately do is commercially discontinue a lot of those products.

While I think they’re doing a good job selling it, I don’t know if it’s in the market’s best interest to have one vendor throwing multiple products into their stable because it doesn’t serve the vendor very well and it doesn’t serve their customers very well. I tend to think vendors that are very exclusively committed to a single product strategy — like an Epic, like a NextGen, like a Greenway — are ultimately going to come out better.

You look at vendors like, even GE, Allscripts — they get weighted down big time with having that many variations of their product. If you look at the legacy vendors — IDX, Misys, Medical Manager, all of which threw out multiple versions of their products because it allowed them to generate multiple levels of support arrangements — at some point in time, that’s just not sustainable, and it’s probably going to be even more difficult to sustain it as requirements for product certification get more stringent. Now they’re going to have to decide who they’re going to cut and who they’re going to keep because it just isn’t practical for these companies to maintain that many overlapping products.

So, the ones doing it better are the companies that have chosen a niche and are sticking with it, as opposed to trying to reach every end of the market?

I would say companies that are committed to a true, fully-integrated, single enterprise solution, versus ones that cobble a bunch of things together. On the low end you have the e-MDs and the eClinicalWorks and the Greenways. In the mid-range you have the NextGens. Allscripts is probably there if you want to segment them towards just a couple of their products.

I don’t think anybody believes the old Misys application’s going to stick around. In fact, they’ve already started sending out letters to upgrade or move over those people. Epic certainly is a clear, good example of a vendor who’s totally committed to their own development, their own product. They have a lot more control over how the product works and performs, and they’re not always relying on third-party cobbled systems together.

Do you think HIMSS includes a good representation of ambulatory providers and vendors?

They didn’t always, but they are now. I think that has been their biggest area of improvement is that they have finally started to reach out to ambulatory. I’m seeing where before, only my hospital clients even knew about HIMSS, and now I’m starting to find that the ambulatory people that we’re working with are attending it and becoming members of HIMSS. I’ve actually seen HIMSS making an effort and trying to reach out into ambulatory.

I also think that that aggressive effort was one of the reasons why TEPR was unsuccessful, because HIMSS, about three years ago, started going after that market and there just wasn’t room for two of them. TEPR did really reinvest a lot of it back into driving attendance, where I think HIMSS, at least they get good attendance. There will probably be a point in time, I don’t know exactly when, where HIMSS may become just a conference to network with your existing customers because of all the selected systems — or until the next thing that re-emerges. But I do think they are really making good strides and progress in reaching out to the ambulatory side.

Do you think that one day they could be a threat to, say MGMA?

You know, it’s funny. MGMA didn’t initially have a lot of IT presence until EMR became popular. Five years ago, if you went to an MGMA conference you found CTAs and billing companies and professional service-type companies exhibiting, but very few vendors. Also, MGMA is almost usually attended by office managers and by administrative.

I’ll give you an example of how trade shows evolved. AMGA, which is similar to MGMA but it’s exclusively focused on large, multi-specialty group practices — they just had their annual conference in New Orleans. I’d say 20-30% of their members are Epic customers and Epic didn’t even have a booth there, but Judy was walking around the floor and meeting her clients. She says, “Hey, I come here to see my clients.”

Very few vendors were exhibiting and the reason why is if you look within that membership and that trade association membership, 90% of those members already have an EMR system. So the few vendors that were exhibiting, they were exhibiting extra modules like patient kiosks, Web portals. They were there to try to sell additional services to their customers. But I think MGMA is going to always have a market because they’re appealing to the smaller primary care ambulatory space; whereas, HIMSS is 100% focused on healthcare information technology and the MGMA covers a much broader range of topics.

What’s your prediction for the physician EHR adoption three years from now?

I think in spite of the stimulus money and whatnot, I think it’s very unrealistic that we can get this many physicians through the system in this short period of time. One prediction I do have is that there will likely be an extension of the stimulus. I do think Obama wants to spend the money and he’ll make it easy. I mean, the bar’s been set kind of low as it is, but I do think that there will be an extension of the deadline so we have more time for more people to get through it.

My fear is that if there is this massive rush, I think that we run the risk of doctors getting first, bitten by a bad experience — which could actually cause us to backslide a little bit. I also think that if there’s a massive rush, then a large percentage of our doctors trying to do this are going to buy systems from “two guys in a truck” EMR company and in three years, we’re going to have to recycle a lot of those people back through because that vendor couldn’t hang with the requirements as they get more difficult each year.

I do think the market’s going to continue to compress. There’s going to be more vendor consolidation and the market won’t have as many players in it, which means that a lot of the early adopters will have to recycle back through.

What percentage adoption do you think will be in say, 2013?

We tried our best to get the exact adoption rates because you know adoption rates have been all over the map, anywhere between 4 and 40%.

The CDC did a study and they concluded that 40% had EHR. Well, it depends on how you ask the question, so they went back and re-surveyed. They said, “Of all you folks that said you have an EHR, how many actually have a certified system, one that meets Meaningful Use requirements as we know it today? Actually uses the system at the point-of-care and has it integrated?” Let me ask the question that way — only 4% said, “Well, if that’s what you’re describing an EHR as, then that’s what I have.” There’s a slag between what people think they have, versus what they really have.

We tried to sort of prove it out ourselves, so we went to the AMA to find out exactly how many physicians there were. We took out all those that worked in academia. We took out those who were physicians, but worked in a hospital, like a radiologist, an anesthesiologist, those that couldn’t really buy an EMR. We took out those who worked in corporate medicine — they’re doctors, but they weren’t practicing. That left us with about 600,000-700,000 physicians who could even buy an EMR if they wanted to. So we said, “OK, well this is real easy now. Now that we know how many people can actually buy one, all we’ve got to do now is go ask the vendors how many systems were actually sold.” We contacted every vendor that we possibly could, and by the time we contacted about 60 of them, the vendors had somehow managed to sell more EMR systems than there were physicians to buy them.

I’m not surprised.

What happens is when you try to get market share from the vendors, they continue to count systems that have been sold, but they don’t ever really go back and count systems actually used. That’s the problem with our reporting. All vendors are counting systems sold, but not actually implemented. I would say that if the vendors were totally honest, 20-25% of systems sold never get implemented. They just stop using it for whatever reason or they change to something else and the vendor doesn’t reconcile their user count because they’re basing it on X number of licenses sold over their years of business. Also, a lot of vendors double count.

Allscripts, I love their statement: “One in every three physicians use Allscripts.” Really? When you unpack that, you may have somebody that’s on an old Medic Plus system that’s been discontinued five years ago. You may have someone using PayerPath; you may have someone using the handheld e-prescribing tool that they have.

But I do think adoption is going to continue to climb. I personally believe that true adoption — using an EMR at the point of care; a real EMR at the point-of-care, not a “lite” or transcription — is probably somewhere between 7-10%. I think in that time period we’ll probably see it move up to 15-20%. I think it also depends on the carrot and the stick. If the stick gets bigger, which it probably will, then we’ll probably see that move a little faster and a little higher.

Any other thoughts or comments you’d like to share?

I enjoy HIStalk. It’s always an honor and a privilege to be asked to contribute. You guys do good work. I’d be happy to do it again in the future.

News 4/1/10

gloStream is the latest EMR to announce a stimulus guarantee program. To qualify, doctors must use the gloStream software “properly,” which includes following gloStream’s gloDNA implementation process. The company says that physicians who follow the correct process will be able to demonstrate meaningful use and thus become eligible for stimulus funding. While I am sure all these guarantees companies are making are on the up and up, I sure wish I had a crystal ball so I could look ahead a couple years to see how all these implementations turn out.

Navicure snatches up a couple of industry veterans for its management team. David Bond, Allscripts’ former Healthmatics division president, is Navicure’s new VP of sales, while ISTA CEO Kernie Brashier signs on as CTO.

IT consulting firm ProviDyn signs on as a reseller for Aprima Medical Software.

Amazing Charts announces the release of  Amazing Charts V5, that includes ePrescribing, a health maintenance component, and order and referral tracking. I also hear that Amazing Chart’s CEO and Founder Jon Bertman, MD will be debating Greenway Medical’s Justin Barnes in a HCPLive-sponsored event. The two will square off April 14th from 12:30 TO 1:30 PM (ET) during a webinar entitled, “Small Vs. Large EHR Vendors: What’s Best for Your Practice.” Register here.

Central Connecticut Medical Management selects Ingenix CareTracker practice management and e-prescribing system for its 16-office, 59-physician group.

Ophthalmic Imaging Solution reports 2009 net losses of $5.5 million, compared to a net loss of just under $3 million in 2008. Revenues increased 8.6% to $13.6 million in 2009. Among other offerings, Ophthalmic Imaging Systems sells a CCHIT-certificated EHR and practice management solution. I don’t know the ins and outs of this company, but as a casual observer, I can’t help be reminded that just because a product is certified and seems well-suited for a particular specialty, it’s always a good idea to check out the financial status of your potential vendor.

Texas Tech University hopes its new Family Medicine Accelerated Track plan will encourage more medical students to choose family practice as a specialty. The program is three years, versus the traditional four, and provides a $13,000 scholarship to each student going into family practice. In other words, less school, less money, plus some scholarship money. I’m not sure I’d pick Lubbock, Texas as a place I’d want to spend three years, but otherwise, it sounds like a sweet deal.

Even though more people than ever turn to the Internet for health information, patients are also trusting their doctors more than ever to decipher the wealth of information available. It turns out patients are increasingly skeptical of information found on the Internet, though they like using the Web to correspond with their doctors. Personally I enjoy surfing every once in awhile, just to assess myself for incurable diseases, like canities.

E-mail Inga.

Intelligent Healthcare Information Integration 3/31/10

Going Full Blown EHR Sorta Sucks

After such a title, please know this up front: I love my EMR…most moments of most days.

What I don’t love, not in the least little bit, is changing how I go about dealing with everything related to patient care information capture, manipulation, and sharing. Converting from a tried and true workflow that has allowed me to provide the best care I’m capable of providing (at least, that’s as true as it could be with paper-based data) to processes that feel foreign and kludgy and downright odd sorta… well… sucks!

After spending our formative years learning how to navigate paper and penmanship (deterioration of the later aside), we are now challenged by the transformation to an almost entirely different way to manipulate our information. Further, it isn’t just how the data goes from brain to storage; it’s how that info is accessed, viewed, and managed.

Sure, we (my staff and I) have all been using computers for a while now (from 3 to 40+ years,) but none of us were even remotely prepared for the overwhelming shift in processes and the enormous learning curves we encounter by going medically electronic.

I’ve tried to think of a comparable or analogous change. Changing how we do banking, changing how we access news and gossip, changing how we buy and window shop, changing how we research and do schoolwork, changing from viewing three television channels which closed shop at 2:00 A.M.to a bazillion — all of these were virtually effortless. We all do all of these things now, even though we weren’t “skillsetted” with them in our youths. None of them seemed like a mountainous climb.

But, changing from free flow data capture, be it for SOAP notes or lab orders, via the familiar pen and paper format to the seemingly simple point-and-click tech of a PC has been, without question, the greatest challenge of my life. (OK, aside from raising kids, maintaining a healthy marriage, dealing with cluster headaches, and remembering to put the toilet seat down, that is.)

It isn’t just how the data goes from head to storage — it’s how everything gets accessed, viewed, shared, and integrated into pre-existing mental categories. My synapses have been strained beyond their original design constraints trying to establish new neural connections and pathways for this completely queer new work style.

I hope I’m not alone when I admit to being exhausted by “change management.” Back in the “pre-EHR days,” it was really easy (relatively speaking) to go to work, see patients, and deliver myself home at the end of the day with some smidgen of energy reserve. Nowadays, my serotonin and dopamine stockpiles are so depleted that I barely have enough left over for fêting my youngest son’s latest fourth grade feat or catching a chuckle from my wife’s current chef-challenged concoction.

Why put myself and my longsuffering staff through all this? Simple. Because, as I said up front, most moments of most days, I absolutely love my EHR. I am daily astounded by the new capabilities I am gaining to deal with data. The upside usually outweighs the downside. It is, without question, worth it.

However, that doesn’t mean this transition time doesn’t sorta suck. It does, big time.

From the trenches…

“Always be yourself…unless you suck.” – Joss Whedon

Dr. Gregg Alexander, a grunt in the trenches pediatrician, directs the “Pediatric Office of the Future” exhibit for the American Academy of Pediatrics and is a member of the Professional Advisory Council for ModernMedicine.com. More of his blather…er, writings…can be found at his blog, practice web site or directly from doc@madisonpediatric.com.

News 3/30/10

From Friend of Don: “Berwick as CMS chief. WOW, WOW, WOW!!! You know he’ll want to change reimbursement schema from volume to value based on day one. Wonder if he’ll be able to turn that big ship in his lifetime?” Dr. Donald M. Berwick runs the Institute for Healthcare Improvement and is a pediatrics and health policy advisor at Harvard. He’s a big advocate of providing better care at a lower cost believes the government and insurers can increase healthcare quality of efficiency by basing payments on the value of service rather than volume. I also noticed a more obscure fact about Berwick: in 2005, he was bestowed an honorary Knight Commander of the Most Excellent Order of the British Empire for his help reforming the NHS.

Sermo and athenahealth release results from a Physician Sentiment Index that indicates doctors aren’t too happy with the business of medicine. A couple of the more disturbing findings: 59% of physicians think the quality of medicine will decline in the next five years and 64% agree their clinical decisions are being based more on what payors are willing to cover than what they think is best for their patients. Not surprisingly, physicians still think EHRs are too expensive to buy, implement, and maintain. Sermo CEO Dr. Daniel Palestrant explains the results in more detail in this CNBC interview.

eClinicalworks says it has implemented 2,000 providers across 400 independent practices in New York City over the last two and half years. Another 600 providers and 100 practices are in the implementation process.

And in the Midwest, physician network Advocate Physician Partners partners with eClinicalWorks and will recommend eCW’s PM/EMR to its 2,600 independent physicians.

North Florida Surgeons selects Allscripts EHR/PM solution for its 34-provider practice. The practice’s CEO says that a key reason they selected Allscripts was the availability of Allscripts Patient Payment Assurance module to to calculate patient responsible amounts and secure payment authorization prior to surgery.

MinuteClinic names Nancy J. Gagliano, MD as chief medical officer. She most recently served as SVP of practice improvement for Massachusetts General Hospital and Massachusetts Physicians Organization.

Theft of personal health information grew from 3% in 2008 to 7% in 2009. Over 275,000 case of medical information theft was reported in the US last year. With increased EHR adoption, medical identity theft is predicted to increase. Furthermore, criminals use information from medical records for 320 days versus 81 days with other types of identity theft. Medical identity theft also takes twice as long to detect.

In more optimistic EHR news, a new NEJM paper supports the use of EHRs to help physicians make more accurate diagnoses. The physician authors believe EHRs can help diminish diagnostic errors in numerous ways, including:

• filtering, organizing, and providing access to data
• fostering thoughtful assessment and collaboration between physicians and patients
• facilitating the documentation of patients’ ongoing and evolving history
• providing better tools for managing patient problems
• ensuring fail-safe communication and action in ordering tests and tracking the results
• incorporating checklist prompts to ensure key questions are asked and relevant diagnoses considered
• providing automated follow-up systems and patient educational tools.

The authors admit that the current generation of EHRs don’t necessarily provide these benefits, but they envision a “redesigned documentation function” that includes improved tools for making diagnoses.

EMR adoption appears to be trending up for practices with 10 or fewer physicians, with 33% of offices planning to implement an EMR within 12 months compared to 11% in August 2009. I was surprised to see that only a quarter of the groups will seek ARRA incentives and a whopping 63% were unaware or unsure of the meaningful use reporting requirements. I’m assuming that latter group doesn’t follow HIStalk too often.

E-mail Inga.

HIT Vendor Executives on Regional Extension Centers

We asked several EMR and consulting executives the following question:

Now that the ONC has announced the initial grants for Regional Extension Centers, what will be the effect on EHR selection and implementation for both the industry and your company in particular?

Michael Nissenbaum, President & CEO, Aprima Medical Software, Inc.

RECs will be gatekeepers, potentially easing or impeding access for EHR vendors to thousands of physicians, community by community. RECs may reduce the complexity physicians would otherwise encounter in evaluating and implementing EHRs. If a REC simply becomes an extension of one or two EHR vendors, physicians could be denied visibility to appropriate technology. Better: RECs should issue an RFP and assess vendors’ strengths and weaknesses by specialty and practice size. Aprima’s ideal for RECs: 80% of our clients are 1-5 physician practices. 70% are in primary care, RECs’ primary target. RECs offering training must consider EHR vendors that will define a training methodology that fits their resources. That should include product training, certification, updates, and more to ensure the success of the RECs and practices. Through Aprima’s certification training and Learning Management System, the physicians will be prepared to meet the “meaningful use” requirements. Aprima’s EHR includes a library of chief complaints, not a collection of templates. This eliminates customization costs. Furthermore, physicians can chart multiple chief complaints in one entry, accelerating encounters. We’ll empower RECs with tablet PCs so physicians can see how a template-free EHR shortens learning curves. Aprima will be a player in the REC paradigm.

Victor Arnold, Managing Partner, AsquaredM

What I am seeing is that our business should grow a bit from this announcement. It will however, likely be a delayed impact (we are a consulting firm). What we are seeing are the EMR/EHR vendors getting stretched thin by the surge in installations along with the clients getting overwhelmed as they truly begin to understand what they have taken on in terms of process change (clinical as well as administrative) and cast about for assistance to either keep their existing operations moving or to sit in the middle between the client IT staff, the vendor install team and the larger organization to help them really integrate the products in a “meaningful” (pun intended) way.

Brad Boyd, Vice President, Culbert Healthcare Solutions

Based on our discussions with RECs across the country, the EHR selection process has largely focused on two main criteria: functionality to support Meaningful Use and Total Cost of Ownership.  EHR vendors with flexible licensing models will be able to compete for this business based on the total value of their offering as opposed to price alone.  CHS is well positioned to assist these smaller practices with their EHR implementations because of our combination of practice operations and clinical transformation experience, as well as our EHR implementation methodology geared towards maintaining physician productivity throughout the EHR go-live process.  While the potential revenue per physician for implementation services will impact margins, we believe it is imperative to resist the temptation to apply inexperienced yet lower cost resources to these engagements, which is a common approach undertaken by many staff augmentation firms.

Girish Kumar Navani, CEO, eClinicalWorks

RECs are responsible for helping primary care providers in small practices with the adoption of EMRs and to help providers get to “meaningful use”. We have a proven track record of implementations in this market segment. We should do well to meet their needs and we are confident that eClinicalWorks has the experience to partner with the RECs to implement the providers required in the timeframe to meet the project milestones. In addition, we are offering free Webinars, onsite assessment workshops and work-force development programs to train both the practices and the REC personnel to better support the deployment and usage of EMRs. As an example we have demonstrated that working with the NYC DOH on the PCIP project we have implemented 2000+ primary care providers in 2 years. Along with the deployment of the EMRs we have partnered with the PCIP (now a REC) to roll-out Clinical Decision Support for preventive and chronic care management and Quality Measure reporting for national quality measures. To be successful, vendors need to be able to implement the EMR and PM on a short timeline, and provide the necessary staffing of project managers, trainers and support personnel along with a comprehensive solution including clinical decision support and measure reporting. eClinicalWorks solutions should meet this criteria both as a company and as a product.

Eric Fishman, MD, Managing Member, EHR Scope, LLC

A saying that was commonly heard in my prior occupation is that ‘if you ask 2 Orthopedic Surgeons how to operate on any individual condition, you’ll get three answers.’  The corollary, I believe, is that if you ask 32 RECs how they will address their grant obligations to assist physicians with their selection and implementation of EHR technology, I believe you’ll receive 33 answers. Obviously, some of the RECs have already ‘chosen’ their preferred vendors, as they have pre-existing business relationships with one or more ambulatory EHR vendors.  Others are more open minded.  Some appear to be moving at warp speed, with extraordinarily rapid RFI timeframes, and others seem to be putting off every decision until they have received reams of information from all potential participants. EHR Scope, LLC has been providing a meaningful (no pun intended) number of services similar to those that the RECs are asked to perform.  For instance, we have 50,000 data points in our database of EHR vendors, and we have already had substantive discussions with a variety of RECs in which they appear to be interested in utilizing and possibly ‘white labeling’ our matching system for their priority primary care providers. This could be done either through www.EMRConsultant.com in which one of our staff (or their staff) analyzes a practice’s requirements, or through http://www.ehrscope.com/emr-comparison/ which provides real-time answers, 24/7. Possibly of most interest have been our educational videos, a few of which can be seen at http://www.ehrtv.com/category/reality-ehrtv/ and http://www.ehrtv.com/category/educational/ in which we document the process of readiness assessment, vendor selection and implementation. We are expecting a very busy 2010!

Tee Green, President, Greenway Medical Technologies

Our experience thus far has been that REC program managers are seeking much of the same reporting and interoperability capabilities that our practices and medical centers desire, with the extra assurance of the ability to exchange with other systems. The standardization that meaningful use is bringing has been welcome. I think for the industry it’s important to keep the focus on the greater healthcare benefits these networks bring, both to underserved populations and the spreading of best practices. It’s also very important for the industry to remember that RECs need to be sustained well past the initial funding years, and that we need to help achieve that. We at Greenway have taken heart in the actual language of the REC funding act, which states in part, “The ultimate measure of a regional center’s effectiveness will be whether it has assisted providers in becoming meaningful users of certified EHR technology.” That’s where the main goal comes full circle; if that is achieved, than Greenway and the industry has done our job.

Hayes Management Consulting, Peter J. Butler, President

The flurry of implementation activity will certainly kick up some dust among vendors, consultants, RECs and physicians. The question is, what will be there when the dust settles? Will it be well executed EHRs that are nicely connected to the practice management system, with staff well trained and physicians supported? Will the $5,000 have been enough?  Hayes is often called in during the middle of an implementation that needs help due to unforeseen costs and resource needs. We work on improving communication to physicians, clarifying goals, and shoring up understaffed help desk teams that aren’t able to respond adequately to users. The RECs are not simply implementing EHRs. They will need to manage the physicians expectations, and build a communications and training infrastructure to ensure a successful phase 1 execution. The effect of RECs on the industry and on Hayes will depend on the RECs’ ability to be successful at this with the funds allotted.

Jay R. Anders, MD, CMIO, MED3OOO, Inc.

The regional centers set up by ONCHIT are to be advisory in nature. Since the certification of EHR technology, most physicians look for the certification first then look at functionality, ease of use, ease of implementation and cost. Once the meaningful use certification becomes final, this will also become a criteria. Physicians will look for advice from consultants and peer references. I don’t think the regional centers will play a great role in helping choose a particular solution. They may play a bigger role in the implementation, especially when it comes to changes in physician behavior that will have to be accomplished to reach meaningful use. Our company has been helping physicians look at their workflow and practice prior to choosing an EHR. This allows for an easier transition into the electronic world. I doubt the regional centers will impact the adoption of our solutions in medium to large practices but may play a role in the smaller groups and solo practitioners.

Scott Decker, President, NextGen Healthcare

It is somewhat hard to answer this question at such an early stage in the evolution of Regional Extension Centers (RECs). We expect about 70 RECs to be created across the country over the course of the coming year and that there may be quite a bit of variability in the model and services provided by each of the individual REC instances. With that said, based on the activity and interactions we have had to date, we do see some trends emerging. RECs are funded by ARRA as implementation and optimization organizations (IOOs) to directly help providers meet Meaningful Use requirements. In this role, they provide complementary and/or alternative services to the implementation programs we offer to new clients. We anticipate RECs will offer additional resources to the market to help ensure the availability of these resources to medical providers to help them achieve a level of EHR usage based on compliance with the 25 criteria for achieving Stage 1 Meaningful Use. We also see the potential for RECs to provide an independent service to our clients who have already completed their EHR implementation phase with NextGen Healthcare, but may now seek additional support on their path to Meaningful Use. Regarding EHR selection, we expect REC endorsement of a specific vendor to help providers increase their confidence that the products they select will meet their clinical needs and qualify for Meaningful Use. Additionally, they potentially provide a streamlined contracting process by pre-negotiating terms and conditions and/or pricing with selected vendors. We do expect that a REC endorsement of an EHR will have the “halo effect” of externally validating the credibility and usability of a product or solution, thereby directly and indirectly affecting purchasing selections. Accordingly, we expect RECs to become an important channel in the market and we are investing significant resources to work with the named and emerging RECs to attempt to create win/win business models for all concerned parties. We look forward to integrating our efforts and significant market experience with the RECs to ensure all current and future NextGen Healthcare clients will achieve Meaningful Use when they are ready.

Andy Riedel, Manager of EHR Marketing, Sage

For those physicians who are actively considering EHR, the RECs may help to narrow the selection, but we anticipate physician buying decisions will continue to be influenced mainly by other physicians.  However, in the area of implementation, the RECs are in a position to fill a much-needed gap, especially around EHR readiness and change management.  Sage customers have had some positive experiences with the QIO/DOQ-IT organizations in this respect, and while the RECs share a similar charter, the potential is far greater this time around, based both on the level of funding awarded and having ARRA/HITECH concurrently driving interest in EHR adoption.  Sage has an installed base of thousands of physicians who are looking to adopt EHR and can benefit from the kinds of services the RECs plan to offer.  We expect to partner successfully with RECs in creating a positive experience for physician practices.

Evan Steele, CEO, SRSoft

Implementation and training is critical to successful EMR adoption. Implementation efforts have had their share of failures, even when they have been conducted by the vendors’ experienced, homegrown, and home-trained experts. When it comes to REC-trained implementation personnel, I have several concerns about what they will be able to add to a process already fraught with challenges. With only six months of training, these implementers cannot possibly be anywhere near as skilled as the EMR vendors’ own team members, who have been working with the companies for years. On which software will these REC implementers be trained to implement? We all know that when you’ve seen one EMR, you’ve seen one EMR! Furthermore, small practices—which lack savvy project managers, lack their own IT experts, and cannot afford to hire outside template designers—are the ones most in need of skilled and experienced assistance to get them across the finish line successfully. Unfortunately, I fear that these practices will also be ones most likely to get relatively untested REC trainers, and I remain skeptical that these implementers, trained for only a short period of time to meet the expected demand for rushed implementations, will be up to the task. The risk is that there will be an increase in what the AMA and 95 other physician societies estimate is an already abysmal 50% to 80% failure rate.