RECs – Considerations for EHR RFPs

Section 3012 of the HITECH act establishes Health Information Technology Regional Extension Centers (REC) that will offer technical assistance, guidance and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of Electronic Health Records (EHRs).  Each REC shall aim to provide assistance and education to all providers in a region, but shall prioritize any direct assistance first to the following:

• Public or not-for-profit hospitals or critical access hospitals.
• Federally qualified health centers (as defined in section 1861(aa)(4) of the Social Security Act).
• Entities that are located in rural and other areas that serve uninsured, underinsured, and medically underserved individuals (regardless of whether such area is urban or rural).
• Individual or small group practices (or a consortium thereof) that are primarily focused on primary care.

So far, ONC has granted over half a billion dollars to 60 RECs to accomplish these goals. One of the first steps the RECs need to take is the evaluation and subsequent recommendation of EHR technologies to their constituents.  Whether the REC selects one EHR to work with, or a short list of preferred vendors, or just a general rating system for multiple vendors, chances are an RFP, or at the very least an RFI, will be issued to EHR vendors.

Following the grant announcement several RECs issued (Requests for Proposals) RFPs and some completed the EHR selection process, while most are still in the process of creating RFPs. The few RFPs currently published are by and large based on the DOQ-IT EHR RFP.  While the DOQ-IT document is excellent for an individual practice, it needs some important adjustments in order to serve a REC’s objectives and stated priorities.

1. Facilitate EHR adoption for several hundreds, to several thousands of providers, in a short amount of time – This objective will require that for an EHR vendor to be considered, it must have the capacity to actually perform such large scale implementations, both in human resources (quantity and quality) and technical infrastructure scalability. The RFP should inquire about both aspects.
2. All REC providers must be eligible for Meaningful Use incentives – Any EHR selected by the REC must be, or readily become, ONC certified for Meaningful Use. Since there are currently no ONC approved certifying authorities, the closest an EHR can come to satisfying this requirement is by already being CCHIT 2011 certified (comprehensive or Stage 1).
3. The first priority for RECs is small Primary Care practices with less than 10 providers – There are two concerns here. First, these practices are usually not cash rich, therefore the EHR licensing model, and any additional fees, needs to be thoroughly explored. Second, there are specific features that are more important for Primary Care and not always available:
   
   a. Full ACOG documentation capabilities and extensive prenatal education materials for OB
   b. Comprehensive Pediatrics module including immunizations schedules for children with special needs and catch-up schedules
4. The initial REC effort will be directed at providers serving large Medicaid populations, rural areas and other medically underserved patients. Physicians and clinics providing services in these areas have very specific needs, not necessarily found in most EHRs.
   
   a. Behavioral Health – Any EHR used for underserved populations must include extensive behavioral health modules or functionality.
   b. Comorbidities – The EHR must allow documentation and treatment of multiple problems in one visit, i.e. loading of multiple templates simultaneously and longitudinal tracking of multiple problems, including patient specific care plans and disease management alerts.
   c. Outreach & Patient Education – In addition to the minimum requirements of MU, underserved populations would be well served by sophisticated outreach tools and extensive, culturally adequate, patient education materials. Specific materials for people with disabilities are also desirable. Just having a PHR is probably not sufficient in areas where there are few computers and health literacy is low.
   d. FQHC functionality – Any EHR used in these settings must have all the regulatory reporting (UDS) and billing capabilities to support federally qualified clinics.
   e. Substance Abuse, Smoking and Obesity – It would be beneficial if the EHR would include content and tools to facilitate counseling along with ability to manage group sessions.
   f. Home Care – Any functionality that allows integration of home care activities into a practice EHR would be beneficial.
   g. Medical Home – Functionality built to better support medical homes creation and operations, such as general care coordination and collaboration, reporting and referral management should be helpful. RECs should inquire if EHR vendor has experience with any PCMH deployment.
   h. Rural Health Connectivity – Considering that most REC implementations will occur in rural settings where broadband and Internet connectivity are not yet as reliable as in urban areas, EHRs should provide contingency plans for ISP outages or lengthy periods of impaired response time.
   i. Patient Volume – Most clinics to be served by RECs have very large and complex patient volumes. EHR ease of use and usability features will be extremely important for successful adoption. Other than testing and evaluating recommended products, RECs should also obtain knowledge of a vendor’s Quality Assurance process and the number of Usability professionals directly involved in product development.
   j. Last, but not least, any EHR vendor selected by a REC should be willing and able to integrate with existing State specific technology efforts to support underserved populations. A good example will be the Indian Health Services RPMS and its Patient Care Component, or any other Medicaid sponsored networks such as MO HealthNet in Missouri.
5. RECs will be engaging in the largest long term EHR implementation effort to date.  It is to be expected that despite best effort some implementations will fail and some practices will be de-installing EHRs. A detailed plan of action for extracting EHR and PMS data from recommended EHR systems is imperative. RECs should inquire about, and contractually request, equitable data extraction processes.

Note 1: Regarding EHR Modules - Although ONC will be certifying EHR Modules, it will be prudent for RECs tol only accept RFP responses from complete products or vendors aggregating modules into complete products. It would not be advisable for RECs to engage in EHR Module aggregation due to the aggressive timelines and shortage of expertise.

Note 2: Regarding Meaningful Use – At the time of this writing CMS has not finalized the minimum requirements for Stage 1 Meaningful Use. It is very likely that the currently proposed requirements will be reduced in scope. However, the 25 certification requirements for EHRs should remain unchanged. Guaranties notwithstanding, EHRs that fall short of those requirements today are less likely to be able to come up to speed and certify in time for the RECs to meet their aggressive schedules. RECs deciding to recommend such EHR products should, at the very least, identify and clearly explain the risk to their providers.