RECs on a Mission: Assessing the Regional Extension Center Program

By Chris Dimick

A year after opening their doors, the federally sponsored health IT regional extension centers have nearly met their recruitment goals. Now the hard part starts…

The Regional Extension Centers (RECs) faced a near impossible mission.

Develop from scratch 62 RECs nationwide, staff them with in-demand health IT consultants, and then convince 100,000 small physician practices and critical access hospitals to either implement an electronic health record system or amp up their current one to meet the government's meaningful use EHR incentive program. And do it in 24 months.

The RECs were not asked to target large healthcare systems, the types of providers most likely to pursue EHR implementations. Instead they were assigned a group historically reluctant to splurge on health IT: small physician practices and hospitals, which traditionally have found EHRs too expensive, too time-consuming, and too difficult to implement and manage.

One year after the RECs formally opened their doors to providers, however, they are expected to meet their first goal-as of September, 90,000 providers had signed up with the RECs, with the remaining 10,000 expected to be signed by year's end.

While this feat is a big accomplishment, the RECs' true mission is just beginning. It only gets harder from here.

Signing up providers is one thing. Getting them to "meaningfully" use EHRs and meet the incentive program measures-which is the REC's ultimate goal-is another. Out of the 90,000 providers enrolled in September, only 1,000 had achieved meaningful use with the RECs' help, according to the Office of the National Coordinator for Health IT (ONC).

The Real Test Awaits

With the hard work just beginning, any impact on the healthcare landscape that the RECs will make is still a few years off.

"Enrollment is important, but it is only the first step of a longer process," says Mat Kendall, director of provider adoption support at ONC, the organization in charge of developing the REC program. "The ultimate goal here is to get people to meaningful use, and we recognize that is going to be a hard, challenging process, especially given the people we are working on."

Over the next three years of the RECs' four-year government contract they will help small physician groups and critical access hospitals use EHRs that bring them government incentives for improving patient care.

"By and large we are trying to change the healthcare workflow for a lot of different practices, and the magnitude of the task is-I don't want to say daunting, I think we can do it-but it is going to be a tremendously difficult, heavy lift," Kendall says.

Small Practices a Tough Sell

The success of the 62 RECs has varied, according to Jennifer Covich Bordenick, CEO of industry group eHealth Initiative (eHI). Overall, she says, it has been a slow start. Some RECs are fully staffed, have exceeded their enrollment numbers, and have begun to see clients successfully attest to stage 1 meaningful use. But other RECs have had a hard time finding providers willing to enroll and still have open staff positions.

eHI has tracked the program since its launch, holding progress update webinars and conducting an annual REC study. It is too early to tell how successful the REC program has been, or whether RECs are having an impact on EHR adoption and health IT use, Bordenick says. But she is optimistic that the program can work.

The real test for the program, according to Bordenick, is whether the RECs reach the small physician practices and the rural doctors, not the early adopters. The early adopters were probably able to meet meaningful use by themselves, she says.

Attestation for the stage 1 meaningful use program opened in April. As of September, 90,650 physicians and hospitals had registered for the Medicare and Medicaid incentive programs. But only about 2,100 physicians had received incentive payments. During a September 14 meeting of the Health IT Policy Committee, Centers for Medicare and Medicaid Services staff said that most of the early attesters had long-established experience with EHRs.

"The hardest group and the largest focus for RECs to sign up are these one- or two-doc offices, and those are always going to need the most resources because they are super busy caring for their patients and don't have a lot of other bandwidth," Kendall says.

Ryan Bush is manager of government strategy, physician practice solutions, at McKesson, an EHR vendor and consultant firm. He sees a similar difficulty convincing small physician practices to invest in an EHR they may not believe they need or believe they can implement.

"Those physicians are the ones that we vendors have been trying to reach out to forever, and [the RECs] are going to need to be creative and very aggressive with their outreach teams," Bush says. "They call [it] outreach, but they are selling a package of services to a very suspicious buyer."

Early Challenges in Staffing

The expectations for the RECs are high, and the timetable to meet goals accelerated. In their first year RECs were expected to organize a business plan, hire staff, educate providers about their services, and sign up thousands. Early challenges included a shortage of qualified, experienced health IT staff and resources, Bush says.

"So if they were to go out and provide advice or education to these providers in a certain area, they just didn't have the experienced staff to really get their message out in a clear, credible, and concise way," he says.

When the RECs were first organized, industry experts feared they would be unable to recruit enough health IT professionals to accomplish their goals. These skills are in high demand in more lucrative areas of healthcare, like vendor organizations and large providers.

Some RECs have hired and trained staff only to have them hired off by vendors and providers, Kendall says. The RECs can only promise employment for the four years of their contracts, after which the success of their sustainability plans will determine their future. Some RECs are fully staffed, but many others are still hiring. Senior management positions have been open for months at several RECs, Bush notes.

ONC anticipated the hiring challenges. Its Community College Consortia program jumpstarted six-month health IT training programs in community colleges nationwide, developed in part to supply the RECs with trained staff.

RECs are hiring, but they will need to be at full staff very quickly in order to move from signing up physician practices to actually helping them select, implement, and optimize EHRs.

Another continuing challenge is getting clients software upgrades from vendors. The meaningful use program has put unprecedented demand on vendors to either update or implement new government-certified EHR systems. Providers need to use a meaningful-use certified EHR in order to successfully attest for incentive payments. RECs and vendors are hard pressed to meet demand.

"That same lack of resources may rear its ugly head as they go out and try to do all these implementations," Bush says. "Because every vendor out there, regardless of what they say, is struggling to keep up with the demand for implementations. As EHRs begin to catch waves, resources are thin not only with the vendors, but also respectively with the RECs."

A Little Help from Friends

Just getting their names and services out to providers has been a challenge. As with any start-up, marketing can be difficult. Many providers don't realize what the RECs can do for them and how heavily discounted their services are.

A survey conducted by eHI shows that over the last year more RECs have been reaching out to local and state medical societies and other private and federal healthcare organizations in order to spread word of their services.

"I think the more that these groups leverage existing organizations and resources, the more successful they're going to be," Bordenick says. "Trying to do this in a vacuum is just not going to be successful."

Vendors have also been vital partners for the RECs. Some RECs offer providers a preferred vendor list, having worked with those vendors to connect to past and current clients in order to offer their services. McKesson has worked with RECs across the country to both educate REC staff on their products as well as introduce RECs to eligible clients, Bush says. McKesson has created promotional mailers, e-mail campaigns, and even user groups to jointly promote EHR adoption and the REC's services.

"I think there was a certain hesitancy from providers very early on, because I don't think there was proper education before the launch of the [REC] program," Bush says. "That is one of the challenges they really faced. They had to first educate providers on who they were."

The partnership between RECs and vendors is mutually beneficial. RECs get introduced to clients, and providers hesitant to work only with a vendor now have a government-funded neutral party helping them plan and manage their implementation.

Since experienced health IT staff are in such demand, RECs and vendors can share resources and fill each other's service gaps in order to handle the influx of implementations.

REC Successes

Not all RECs have had problems. Some have moved past early challenges and are helping providers meet meaningful use.

In September the Telligen Health Information Technology REC based in Iowa was just 100 physicians shy of its goal to register 1,200 participants, and it expected to meet its target by the end of the year. In total, the Telligen REC has recruited nearly 70 percent of Iowa's independent practices to take part in the program since launching in spring 2010, a big accomplishment, notes Sarah Cottington, MHA, RHIT, CPHQ, the REC's quality improvement advisor.

Even though they are still recruiting, the Telligen REC has begun helping clients implement or leverage EHRs and meet meaningful use. They found it can take between two and nine months, and sometimes longer, to get providers from sign up to attesting for meaningful use, depending on their EHR experience.

Nationwide, many providers come to the RECs using only paper processes, and the RECs start from scratch in working toward stage 1 meaningful use attestation.

Sometimes it is just a matter of implementing aspects of an EHR, like computerized physician order entry. Because it is complex to implement, many facilities have avoided CPOE. But meaningful use measures require its use, so some facilities are turning to the RECs to help implement the system.

Those facilities who already have a certified EHR receive guidance and education on adapting their electronic processes, workflow, and patient care to meet the meaningful use measures, Cottington says. The RECs do more than just enter a provider practice, plug in an EHR, and leave. They also address the need to change staff culture to perform in a way that will meet meaningful use and optimize the EHR.

The Telligen REC has had several providers successfully attest to stage 1, including Cass County Health System.

Helping out at Cass County Health System

While small providers are key targets of the REC mission, rural and critical access hospitals are also eligible for their help. More than 800 critical access and rural hospitals with 50 beds or fewer had enrolled in a REC program as of September, according to ONC. Iowa's Telligen REC was second in the nation, behind Kansas, in working with hospitals, signing up more than 60 facilities.

One of those is Cass County Health System, a small physician group and critical access hospital based in Atlantic, Iowa, that has used the Telligen REC for both its physician offices and hospital since 2010.

The affordability of the REC, its connection to Iowa Medicaid, and its detailed offerings initially attracted the health system to the program, according to Steve Stark, MHA, the assistant administrator/CIO and HIPAA privacy and security officer at Cass County. On the hospital side, the subsidized REC services cost only $1,000.

The REC conducted a workflow analysis that identified processes in need of change in order to meet meaningful use. REC staff spent several days on site talking to clinicians and front office staff and observing workflow before submitting a written plan of action that would guide the system to meaningful use.

In the end, the physician group has seen improved population health, has more physicians on board with e-prescribing and CPOE, and feels it is using its EHR in more meaningful ways, Stark says. The hospital attested to stage 1 in September, with the physician group planning to attest by the end of the year.

The REC's independent, consultative role can be effective, Stark says. "If you're used to doing things a certain way, sometimes hearing [recommendations] from a third party it's a bit easier to get some change made," Stark says. "The nice thing is they're really considered, at least for us, industry experts… I always tell people that it's nice to just have a phone number that you can call when you have a question about some of the criteria or how to attest."

The RECs provide expertise that typically would be beyond the budget of a smaller hospital or physician group. While a larger organization might have a whole team devoted to EHR implementation and meaningful use, smaller facilities like Cass County cannot have staff devote weeks at a time researching special projects.

"If you're a small organization like us, [the REC] is essential," Stark says. "I know there are some CIOs out there that are paying way more than we are [for consulting] who have not attested yet and are way further away from attesting than we are."

For Buena Vista Regional Medical Center, a 25-bed critical access hospital based in Storm Lake, Iowa, hiring the Telligen REC gave it a jumpstart it could not have received otherwise.

"What the REC provided for us we could have done, but it would have taken us a lot more time and energy. They helped us be more efficient because they had the assessment tools in place, they had educational information in place, they had all the meaningful use objectives broken down," says Lori Cherrier, RHIA, director of HIM at Buena Vista. "It was more efficient for us to absorb and move forward. We didn't have to do a lot of research and spend a lot of time and effort figuring it all out for the first time ourselves."

Mission Hard, but Not Impossible

While the RECs continue to maneuver the difficult and sometimes hostile healthcare landscape, it is clear they are making progress on their mission.

Getting 100,000 primary care providers to commit to meaningfully using EHRs represents an important first success, Bush notes. The engagement with typically hard-to-reach, small physician offices and hospitals is unprecedented. But the real impact will come when RECs successfully help providers use those EHR systems for improved care-when the RECs begin what Bush calls "less talk, more do."

ONC's Kendall agrees.

"That is a pretty big impact in terms of getting those people to say, 'I want to move towards meaningful use.' I think that illustrates a change in perception out there that we are moving in the right direction," Kendall says. "But we are really looking forward to when providers begin hitting meaningful use in large numbers, and we think that will be soon."

Chris Dimick (chris.dimick@ahima.org) is staff writer at the Journal of AHIMA.