In the proposed rule released April 9, 2012, which offered a delay of ICD-10 compliance until October 1, 2014, the Department of Health and Human Services (HHS) also announced its intention to require the use of health plan identifiers (HPID). 

The change, proposed as part of the Affordable Care Act, would standardize the identifier health plans and other third party administrators use when processing claims within the healthcare industry.
Currently, there is no uniformity in identifiers used by health plans.

Plans commonly use employee identifier numbers (EIN) and tax identifier numbers (TIN) in electronic claims transactions, as well as other proprietary numbers. The establishment of the HPID will set a common standard that would simplify administrative processes and, according to language in the proposed rule, save as much as $4.6 billion over the next 10 years.

The rule states that the HPID simplify operations for providers, and that the initial cost to implement the change will be directed at the health plan insurers.

HHS has proposed two types of identifiers:  controlling health plans (CHP) and sub-health plan (SHP), that will consist of 10 unique numeric digits.

Pre-implementation work on the identifiers has been conducted since 2010 by government bodies such as the National Committee on Vital and Health Statistics, the Workgroup for Electronic Data Interchange (WEDI), and other organizations.

The HPID will have several unique uses that directly affect HIM professionals. These identifiers will be part of the patient medical record for identifying healthcare benefits, contained in Health Information Exchanges, and used in public health reporting requirements.

Click here for more details on the HPID and other identifier information.

Other objectives featured in ACA that are expected to soon be released by HHS, according to the HPID proposed rule, include more measures to reduce administrative costs, final rules from the HITECH Act that will update HIPAA law, actions to ameliorate reporting problems relating to Medicare Part D plans, and rules increasing the use of electronic transactions.

Wendy Zumar, MA, RHIA, CCS, (wendy.zumar@ahima.org) is an independent terminology and coding consultant based in Aurora, CO.
 

The investigation followed a report from BCBST that 57 computer hard drives were stolen from a locked data network closet in a leased office facility. The drives contained the unencrypted protected health information of more than one million individuals, including names, Social Security numbers, diagnosis codes, dates of birth, and health plan identification numbers.

BCBST had relocated staff from the facility but not yet moved the computer equipment. An investigation by HHS’s Office for Civil Rights determined that BCBST failed to implement appropriate administrative safeguards by not performing a security evaluation in response to the operational changes. The investigation also showed a failure to implement appropriate physical safeguards, according to the resolution agreement. Both safeguards are required by the HIPAA security rule.

In addition to the monetary settlement, BCBST agreed to a corrective action plan to review its HIPAA compliance program and address gaps.

The agreement is not an admission of liability by BCBST or a concession by HHS that the covered entity is not in violation of HIPAA. Instead, the two parties agreed to a settlement to avoid further burden and expense of investigation and litigation.

The breach notification rule, a provision of the HITECH Act, established requirements for how covered entities must respond to breach incidents, including notification of the affected individuals and HHS. Breaches affecting 500 or more individuals must be reported to HHS within 60 days and are posted on an HHS Web site. Covered entities have reported 400 such large-scale breaches involving more than 19 million people since reporting began in September 2009.

Locked, but Stolen

The BCBST breach is one of the largest on HHS’s list, as well as one of the first.

BCBST reported the incident on November 3, 2009, approximately a month after employees discovered the theft and less than two months after the breach reporting requirements became effective. The Office for Civil Rights opened its investigation on January 8, 2010.

The data network closet was secured by biometric and keycard scan security with a magnetic lock and an additional door with a keyed lock. The property management company also maintained security services.

According to BCBST, it received an alert on Friday, October 2 that the server at the leased facility was unresponsive. The alert included no indication that a theft had occurred. Staff did not investigate until Monday, October 5, because the unresponsive server did not appear to adversely impact operations.

The stolen hard drives were part of a system that stored audio and video recordings of customer service calls. The audio and video data had to be manually and individually reviewed to obtain access to the protected health information.

The Corrective Action Plan

Under the terms of the corrective action plan, BCBST will provide HHS with its policies and procedures related to the privacy and security rules and then revise them as HHS indicates. BCBST will then have 220 days to demonstrate that it has implemented any revisions.

The plan also describes how BCBST must distribute the revised policies and procedures and conduct training on them.

The resolution agreement includes detail on the monitoring program BCBST will be required to implement as part of the action plan. HHS will have the right to access records related to BCBST’s monitor reviews. The requirements of the monitoring program begin on page 4 of the resolution agreement.

ONC’s rule defines the technology standards and implementation specifications that will support the new and revised objectives and measures for stages 1 and 2 of the meaningful use program. Effective 2014, EHR technology must be certified against these criteria to be used in the program. The rule also proposes a change to the definition of a “qualified” EHR that would allow providers more flexibility in the scope of the systems they implement.

The rule is titled “Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology.” The Federal Register has filed it under the pithier name “Electronic Health Record Technology, 2014 Edition.”

Publication of the rule in the Federal Register is scheduled for March 7, coinciding with publication of the stage 2 proposed rule.

Classifications and Terminologies

ONC proposes the use of SNOMED CT for problems lists and clinical quality measures. The International Release January 2012 version would be required.

ICD-10-CM and –PCS would be used for encounter diagnoses and procedures.

However, with HHS’s recent announcement that it intends to delay ICD-10 implementation, ONC requests industry comment on whether it should be “more flexible” with the proposed requirement based on “any potential extension of the ICD-10 compliance deadline or possible delayed enforcement approach.”

Further, ONC asks whether it would be more appropriate to require EHR technology to be certified to a subset of ICD-10, either ICD-9 or ICD-10, or to both ICD-9 and ICD-10 for encounter diagnoses and procedures.

For procedures, ONC would continue to permit a choice for EHR technology certification, either ICD-10-PCS or the combination of HCPCS and CPT–4.

Preliminary cause of death would be reported using ICD-10-CM to take advantage of the increased specificity the code set provides.

LOINC 2.38 would be required laboratory tests, and RxNorm would be used for medications.

The Consolidated Clinical Document Architecture (CDA) standard is the only recommended standard for summary transactions.

Stepping Up Security

New security criteria in the rule reflect increased security requirements of CMS’s rule, including a requirement that systems encrypt data at rest.

New requirements also reflect updated patient engagement objectives, including a “patient accessible log” to track the use of the view, download, and transmit capabilities. Beginning in 2014, systems would be required to record a user’s identification, actions, and the health information viewed, downloaded, or transmitted and make that information available to the patient.

Support for Patient Access

In response to new patient engagement objectives, EHR technology would be required to support a patient’s ability to view, download, and transmit his or her information to a third party.

Systems must be capable of generating patient summaries, and in ambulatory settings systems must enable secure messaging with providers.

A Shift to “Base EHRs” in 2014

ONC also proposes changes to its definition of a “qualified” EHR intended to give providers more flexibility.

In response to feedback, ONC would allow professionals and hospitals the ability to implement only the EHR technology they need to demonstrate meaningful use.

Under the current definition, program participants must have EHR technology that has been tested and certified to all applicable certification criteria adopted for the setting for which it was designed. Thus, for example, an eligible professional who qualifies for an exclusion of an objective and associated measure still must have EHR technology that supports the capability.

Effective 2014, ONC’s rule would require professionals and hospitals to possess a “base EHR” that supports universal fundamental capabilities. They then would require any additional technology necessary to meet the program objectives and measures for the stage of meaningful use that they seek to meet and to capture and report clinical quality measures.

The revised definition reads: “All EPs, EHs, and CAHs must have EHR technology (including a Base EHR) that has been certified to the 2014 Edition EHR certification criteria that would support the objectives and measures, and their ability to successfully report the CQMs, for the MU stage that they seek to achieve.”

Comments on the rule will be due in early May, 60 days following publication.

The proposed rule maintains the direction of the program set in stage 1, with a focus on increased requirements for health data exchange and patient engagement, as expected. The provisions generally reflect the recommendations of the Health IT Policy Committee made last year. .

Deadline Changes, Shuffled Objectives

Within the rule CMS proposes changes to the stage 2 timeline that would give providers who demonstrated meaningful use in 2011 a one-year extension in advancing to stage 2.

Under the modified deadline, such providers will have until 2014 to graduate to stage 2, which would create a single start date for stage 2.

The modification was first announced in late 2011, when it became clear that stage 2 rulemaking was running so late that vendors and providers would have insufficient time to meet the original deadline.

The rule proposes new objectives for stage 2, eliminates some, and combines others.

With two exceptions, the objectives from the “menu” set in stage 1—a list of 10 items from which providers were required to choose five—would be required in stage 2. There are new objectives with greater applicability to specialty practices.

Stage 2 would retain the core-menu approach. Eligible professionals (EPs) would have 17 core items and choose three of five menu items. Eligible hospitals (EHs) would have 16 core items and choose two of four menu items.

Nearly all stage 1 core and menu objectives would be retained in stage 2. However, some stage 1 objectives would be combined into more unified stage 2 objectives.

Raising the Bar on Patient Engagement

As expected, the proposed rule advances the patient engagement objectives. A new measure would require that more than half of an EP’s patients receive online access to their information within four business days of the information becoming available to the EP. More than 10 percent of patients must view, download, or transmit their information.

Hospitals would be required to offer inpatient and emergency department patients online access to information within 36 hours of discharge. More than 10 percent of patients must view, download, or transmit their information.

The objective would replace the stage 1 requirement to provide patients with electronic copies of their information.

The patient engagement objectives in stage 1 requirements have challenged providers, many of whom have found that their processes and IT systems are ill-prepared to provide patients with copies of their information within days, especially in electronic format.

Other proposed measures in stage 2 include secure electronic messaging to communicate with patients on relevant health information. As proposed, more than 10 percent of an EP’s patients must send a secure message using the messaging function in the provider’s EHR.

Easing Quality Measures Reporting

Acknowledging the challenges the industry currently faces in reporting quality measures, CMS proposes better alignment of stage 2 measures with existing programs, such as PQRS and Joint Commission accreditation.

EPs would report 12 clinical quality measures, and EHs would report 24. The rule also proposes a means to submit measures electronically and solicits comments on other methods.

Practices would be allowed to upload quality measures in batches, enabling them to report measures collectively for all physicians rather than individually.

What’s Next

Comments on the rule will be due 60 days following publication in the Federal Register.

AHIMA will release its comments on its Advocacy and Public Policy Center site in advance of the submission deadline. The Journal will offer summaries and analyses of the rule online and in print during that time.

CMS intends to publish a final rule in the summer.

A companion rule detailing the standards, specifications, and certification criteria for EHRs used in the meaningful use program is expected at any time. The rule will reflect the new or heightened standards and functionality EHR systems will require to support the objectives of the stage 2 rule.

[Editor's note: the certification rule, released February 24, is reviewed here.]

The Office of E-Health Standards and Services reported the numbers at a December 7 meeting of the Health IT Policy Committee. The data are preliminary; CMS expects to release final numbers for the month on December 13. (This article was updated December 19 with final numbers.)

Registration Tops 157,000

More than 157,000 professionals and hospitals had registered for the program through November, according to OESS. Of those, the majority are EPs registered for the Medicare program (114,925, or 73 percent). Approximately 40,000 EPs are registered for the Medicaid program.

Nearly 2,900 hospitals had registered through November. More than 90 percent are registered for both the Medicare and Medicaid programs; hospitals can register for both programs without committing to attesting to each.

Payments Rising Steadily

One measure of successful attestations is incentive payments. Payments jumped significantly in November after having risen on a strong curve over a six-month period.

Nearly 7,000 providers received payments in November, up  from 4,160 in October and 1,168 in June. Payments in the Medicare program began in May of this year, and Medicaid payments in some states were available in January.

OESS reports that 22,636 professionals and hospitals have received more than $1.8 billion year-to-date. One-third of that money was paid in November. The share of payments through the Medicare and Medicaid programs was nearly equal.

Eligible professionals have until February 29, 2012, to register and attest to receive an incentive payment for calendar year 2011. Hospitals had until November 30 to receive a payment for federal fiscal year 2011 under the Medicare program.

	YTD Providers Paid	YTD Payments
*215 hospitals received payment under both the Medicare and Medicaid programs.
Medicare EPs	10,155	$182,790,000
Medicare hospitals*	411	$737,501,216
Medicaid EPs	11,140	$234,171,286
Medicaid hospitals*	802	$674,784,072
Total	22,508	$1,829,246,574

Under the original rules of the meaningful use program, providers who adopt health IT in 2011 (and register for the program through February 2012) must progress to stage 2 of the program in 2013. Providers who do not join stage 1 until 2012 have until 2014 to meet the stage 2 standards. Both groups, however, are eligible for the same total incentive payments.

Under the modified deadline, providers that adopt health IT this year will now have until 2014 to graduate to stage 2. The change would give providers currently in the program an extra year to prepare for stage 2. In total, early adopters would have three years in stage 1.

The extension also removes a disincentive to delay joining the program. HHS clarified that providers attesting to meaningful use by February 28, 2012, will be eligible for the 2011 as well as the 2012 incentive payments.

The extension is a reflection in part that under the terms of the original rule providers who joined the program in 2011 would have only a few months to prepare for stage 2. A final rule on stage 2 is not expected until summer 2012, and hospitals would be required to meet the requirements on October 1. That would leave little time for both vendors and providers to prepare.

HHS will propose the extension in the notice of proposed rulemaking on stage 2, which is scheduled to be published in February 2012, according to a fact sheet published by HHS’s Office of the National Coordinator for Health IT.

ONC’s fact sheet also includes progress updates on the meaningful use program and related ARRA programs.

The launch of the permanent program, which will replace the temporary program in effect since June 2010, will now coincide with the release of the stage 2 meaningful use final rule and the attendant release of new standards and certification criteria.

The delay also allows ONC more time to develop and approve the authorized certifying bodies (ONC-ACBs) that will evaluate EHR systems against the meaningful use requirements.

“We believe aligning the sunset of the temporary certification program with the effective date of this forthcoming final rule would provide certainty to healthcare providers, EHR technology developers, and other stakeholders, while also ensuring a sufficient number of accredited testing laboratories and ONC-ACBs exist to meet market demand,” wrote Farzad Mostashari, the national coordinator for health IT, in a notice of the delay published in the November 3 Federal Register.

The January 1, 2012, date was never set in stone. ONC made it clear when releasing a final rule on the permanent program this past January that it would delay the start as necessary. The target date had been at the request of the industry, which sought a date for planning purposes.

ONC made the decision after consulting with the American National Standards Institute and the National Institute of Standards and Technology. Both organizations play a role in accrediting organizations to test and certify products under the permanent program.

“We base this conclusion on ANSI and [NIST’s] estimations of the amount of time needed to complete the accreditation of certification bodies and testing laboratories, as well as our estimation of the time period for the National Coordinator to review the applications of accredited certification bodies and subsequently authorize them as ONC-ACBs,” Mostashari wrote.

The delay has no immediate impact on vendors or providers. EHR products certified under the temporary program will remain certified under the permanent program, regardless of the transition date. Products will require new certification only when the stage 2 meaningful use final rule establishes new or modified system requirements.

Certification bodies approved for the temporary program must re-apply under the permanent program.

There are currently six testing and certifying bodies participating in the temporary certification program. They have certified approximately 1,200 EHRs or EHR modules to date.

The Office of the National Coordinator for Health IT, which created the program, has always considered the grants as start-up funding, intending that the RECs find their feet and continue assisting providers past the length of the contracts. This past January it relieved some of the pressure by modifying the funding to provide greater support for the centers in the second half of the contracts.

Saving Money for Implementation

The REC grants cover a four-year period ending in 2013. Originally ONC planned to reimburse the extension centers for 90 percent of the costs per provider in the first two years of the contract. The RECs would be responsible for the remaining 10 percent. In the second two years that ratio would flip, with ONC covering 10 percent, and the RECs responsible for 90 percent.

However, ONC soon realized it had underestimated the time it would take the RECs to become self-sufficient. In January 2011 the office announced it would pay 90 percent of the costs per provider throughout the full four years of the program.

ONC did not issue additional grant money. It only adjusted the rules for how it will pay out the money. The change means that RECs will receive steady funding throughout four years, but without additional money, they need to reconfigure their budgets. They must spend less money on the front end or work with fewer providers.

The extension was meant to ensure RECs had sufficient funding during the last two years of their contracts, when the majority of their actual implementation work with providers would occur. (RECs have spent their first year becoming operational and recruiting providers to the program.)

ONC says the change was also made to take the burden off of providers, who likely would have been charged higher fees by the RECs to make up the funding difference. A number of competing priorities such as ICD-10 and the HITECH modifications to the HIPAA privacy rule have stretched most small providers thin, and ONC recognized a change in funding was needed.

“We wanted to make sure that we took off financial pressures, especially given these tough economic times, from providers [who] were already putting a lot in,” says Mat Kendall, director of provider adoption support at ONC. “We didn’t want to overtax them and wanted to do everything in our power to make sure that [the RECs] were successful.”

RECs also needed more time to get their operations streamlined and develop tried and true methods for working with providers before funding was reduced, says Sarah Cottington, MHA, RHIT, CPHQ, the quality improvement advisor at the Iowa-based Telligen HIT Regional Extension Center.

“I think all of us felt like to really get the job done and provide real help to providers, [funding] was going to have to be more than just a year,” she says. “Everyone could see that it was going to take more time than that.”

Independent industry analysis also praised the contract revision. The change was a good sign that ONC and the RECs were committed to the mission and that ONC would not let the RECs “die on the vine,” says Jennifer Covich Bordenick, CEO of healthcare industry group eHealth Initiative (eHI).

“We’re in a really difficult economy right now, and there are a number of competing priorities,” Bordenick says. “Doing this is hard anyway, even in the ideal conditions, when the wind’s blowing your way and everything going great. Even in those conditions this implementation and adoption is difficult.”

Becoming Sustainable

Now that solid funding has been spread over the initial four years of the program, the RECs’ ultimate goal is to develop self-sustainability models that allow them to remain open well past the length of the grants. That will be the biggest challenge RECs face as they near the end of their fourth year in 2014, Bordenick says.

The RECs “have to find a really valuable service that physicians want to buy, so they need to be providing technical assistance or help that is valuable, that doctors are talking to each other about, because there are a lot of groups that can help with this— vendors, consultants, et cetera,” she says. “So the RECs need to distinguish themselves.”

eHI’s 2011 REC survey showed that RECs are considering several approaches to sustainability. The most popular is a paid membership model offering consulting services for physicians and specialists that include training, assistance with practice management, and quality improvement.

“I think there are a lot of different models that are being developed right now that we are looking to see, looking to test, itemize best practices, and then launch,” Kendall says. “Implementing the system is just the first step. We always said it is about meaningful use, and we think meaningful use is the first step in a longer process toward quality improvement, improved healthcare efficiency, and improved population health.”

 Some RECs are tying their model into federal national quality strategy programs that will soon launch. RECs would charge for services to help providers become accountable care organizations and patient-centered medical homes, help facilities meet upcoming pay-for-performance quality measures by offering quality analytics, and act as a consultant on the later stages of meaningful use.

Some RECs like Telligen HITREC may seek to expand their client base. They would continue to recruit providers for EHR and meaningful use consulting, but move beyond the small and rural providers targeted in their ONC grants and open up services to physicians and hospitals of any size.

For more on the RECs’ first year, see “RECs on a Mission.” For the role of HIM in the REC’s work, see the “REC Connection.”

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.”

The path to meaningful use runs through the HIM department.Meeting the requirements of the federal EHR incentive program requires the contributions of HIM professionals to redesign documentation workflow, implement new health IT systems, and capture quality measures.

For that reason, regional extension centers (RECs) routinely work with HIM departments when they consult with providers on how to meet the meaningful use program requirements.

HIM staff help is critical to a provider’s success, says Sarah Cottington, MHA, RHIT, CPHQ, the quality improvement advisor at the Telligen Health Information Technology Regional Extension Center, based in Iowa.

When Cottington enters a healthcare facility for REC work, she always checks to see if an HIM representative is on the steering committee or involved in the meaningful use effort. If one is not, she explains how privacy and security, documentation workflow, and several stage-1 measures like electronic reporting of health information all require HIM input.

“Even though a hospital may not think the HIM professional is needed or required—that it’s all IT—I try to make it very clear from the beginning that the HIM professional needs to be involved,” she says.

As an RHIT and CPHQ with extensive quality work in hospital HIM departments, Cottington knows the value of having HIM involved in the planning. Take for example, she says, the stage-1 requirement to provide patients with electronic copies of their information within three days. HIM staff are necessary to help write the policies and procedures, design workflow, and train staff on operations.

RECs routinely help hospitals develop problem lists, another stage-1 measure. The Telligen HITREC always includes coding professionals in developing the list and its processes, “because it’s all based off the current codes of the patient,” Cottington says.

An HIM Role at Buena Vista Regional Medical Center

When Iowa’s Telligen HITREC worked with Buena Vista Regional Medical Center, a 25-bed critical access hospital based in Storm Lake, Iowa, the HIM department played a key role in the process.

Fresh off an EHR implementation, Buena Vista had the REC conduct an analysis of its electronic processes to show any gaps in meeting stage 1 meaningful use, says Lori Cherrier, RHIA, director of HIM at Buena Vista.

The Buena Vista HIM department mainly worked with the REC at the “administrative strategic level” and not at the coding or record analysis level.

REC staff educated the facility on the details of the meaningful use criteria, numerators and dominators needed to measure the criteria, and assessed how close the facility was to meeting stage 1. The REC also benchmarked Buena Vista’s stage 1 readiness versus other facilities in the state. A section of that evaluation focused on maintaining privacy and security requirements while taking part in the program, requiring HIM staff input.

The release of information processes needed to be reworked in order to give patients copies of their discharge instructions and other medical records within three business days, a stage 1 measurement.

HIM staff also worked on adapting the EHR to collect information for the quality measure reporting aspects of the program. This has been a problem for many providers since most EHRs don’t inherently have the functionality to meet the measure, Cherrier says. HIM was key to solving the problem.

“The REC was helpful in helping us identify other organizations around the state that are in the same situation as us so we can hopefully try to work together and find a process that works,” Cherrier says.

Due to the RECs help, Buena Vista is on track to attest to stage 1 meaningful use next year.

HIM involvement with the REC planning helps ensure the health record remains sound and secure during meaningful use focused redesigns.

“We’re the ending point for all the patient information,” Cherrier says. “We do all the reporting, the release of information, maintaining the record. Even though we’re on the back end of the process, we need to be very involved in the front end so it’s not a mess on the back end.”

For more on the REC program, see “RECs on a Mission” in this month’s issue.