DOQ-IT Déjà vu
The regional extension center program might have some people experiencing déjà vu.
Granted, the REC program is an unprecedented attempt by the federal government to transition American healthcare to electronic health record systems. Split between 60 RECs nationwide, a total of $643 million will be used through the HITECH Act to implement EHR systems in tens of thousands of physician worksites. Mass health IT implementation on this scale has never been attempted in U.S. history, but that doesn’t mean some of the RECs haven’t been here before.
That’s because many REC organizations have direct experience operating a similar program—called DOQ-IT—just two years ago. They plan to leverage that experience as they once again work with physicians to implement health IT.
DOQ-IT and RECs
Of the 60 RECs, 15 have been developed directly by quality improvement organizations (QIOs), and several more have contracted with QIOs in a supporting role or hired former QIO staff.
QIOs are state-based, independent organizations that contract with the Centers for Medicare and Medicaid Services on projects to improve healthcare quality. Every three years, CMS issues a scope of work that lays out a new set of quality improvement activities.
From 2005 to 2008, the eighth scope of work included the DOQ-IT program, which charged QIOs with helping physicians analyze, select, and implement health IT and EHRs. Each QIO was to work with at least 5 percent of the practices in its state to achieve EHR implementation.
While the DOQ-IT and REC programs do have differences, the heart of each is the same, and when the Office of the National Coordinator for Health IT solicited organizations to apply for REC grants, several QIOs recognized the opportunity to use their experience in DOQ-IT on a larger scale.
The experience gained from the DOQ-IT program by QIO staff has been “monumental” as those organizations develop RECs, according to Anita Somplasky, RN, the former DOQ-IT director at QIO Quality Insights of Pennsylvania and current executive director of the REACH East and West Pennsylvania RECs, which Quality Insights developed.
“If we had not done DOQ-IT, I wouldn’t have thought that we were qualified for REC,” Somplasky says. “Having [met] face to face with other RECs, the non-QIO RECs are having a hard time wrapping their heads around the way government projects work.”
Time Is Short, Experience Counts
Providers who implement EHRs that meet HITECH criteria will receive CMS incentive payments beginning in 2011. But starting in 2015, those that do not will receive reduced CMS payments. That tight time frame does not leave the RECs much time to become operational and effective. Leveraging DOQ-IT has been a way for some RECs to get up to speed on what it takes to transition groups of physicians to EHRs.
DOQ-IT was essential to the development of the Wide River Technology Extension Center, the Nebraska REC developed by QIO organization CIMRO.
“DOQ-IT gave us the knowledge of the EHR environment in Nebraska. We were able to understand what products are out there and how people are using them, what some of their challenges are,” says Greg Schieke, MBA, Wide River’s senior vice president.
“It gave us a better understanding of the dynamics of how clinics make decisions in purchasing and utilizing technology. It was just extremely important.”
Replicating the DOQ-IT Structure
Implementing an EHR in a physician practice is not as simple as plugging in some wires and firing up a machine. Each practice has its own implementation issues and challenges, and no two EHR implementations are ever the same, says Kim Downs, RN, CPHQ, the senior director of operations at IFMC, which developed the Iowa REC. This is a DOQ-IT lesson Downs will remember as she leads IFMC’s REC operations.
Many QIO staff that headed up the DOQ-IT program are now transitioning within their organizations to work on the REC. IFMC staff directly referenced the composition of the DOQ-IT team and modeled the IFMC REC structure after it.
“We looked back at how the DOQ-IT team worked, what were some of our successes, what we felt went well, and what didn’t go so well,” says Sandy Swallow, CMA, CPHIT, the lead quality improvement advisor at IFMC.
Swallow will be one of several REC staff members who work directly with practices during EHR implementation—just as she did two years ago in DOQ-IT.
Lesson Learned: Hands-on the Best Approach
DOQ-IT is serving as the main source of information for the joint Wyoming and Montana REC, developed by QIO Mountain-Pacific Quality Health. The Health Technology Services Regional Extension Center’s Wyoming portion is managed by the former Wyoming DOQ-IT director, Kris Urbanek, MS.
The lessons learned implementing EHRs in DOQ-IT will make operating the REC much more effective, Urbanek says. Some non-QIO RECs are taking a remote, high-level approach to implementations. But after Urbanek tried different techniques in DOQ-IT, he found the hands on, in-person implementation approach proved most effective in Wyoming. The way the Wyoming REC operates would likely be different if Urbanek didn’t have the lessons of DOQ-IT to reference, he says.
“DOQ-IT made it very clear that we can only be successful by being very involved with practices,” Urbanek says. “Because certainly we tried a variety of approaches over those three years as the DOQ-IT QIO. What really worked best is when you had interested practices that you were working with hands-on, and every other approach that we tried to do wasn’t quite as successful.”
In Iowa, Swallow also attributes part of IFMC’s DOQ-IT success to staff working directly with practices through each step of the process. Staff helped recruit the practices, tailor the implementation tools, educate practice staff on transition details, and step by step guide them through the EHR implementation. That process is being duplicated in the REC project.
The most successful implementations in DOQ-IT were those where the focus was less on the EHR vendor selection and more on developing strong change management practices, improving quality of care, and personalizing staff education, Downs says. Taking this lesson to heart, the Iowa REC has hired three quality improvement advisors for every one technical EHR advisor.
“We found direct, in-the-office contact with providers and staff to be very beneficial and successful in the DOQ-IT program,” says Marlene Hodges, quality improvement advisor at IFMC. “It forged that relationship with the folks in the office and allowed them to gain trust in our expertise and credibility with the program.”
This “consultative model” of EHR implementation will be the key to a REC’s success, Somplasky agrees. No two practices are the same, and trying to implement all practices in the same fashion will lead to failure, a lesson learned in DOQ-IT.
“If you’ve seen one implementation, you’ve seen one implementation,” Somplasky says. “No matter how much extra it costs, [the consultative model] is what you have to do if you want to succeed in this.”
Lesson Learned: Focus on the Culture
The IFMC Iowa REC learned from DOQ-IT to abide by the 80/20 rule in EHR implementations. While vendor selection is very important, it accounts for only 20 percent of a successful EHR implementation, Swallow says. The other 80 percent should focus on changing the culture and environment in the physician office.
That change involves open, upfront discussions about the practice’s expectations from an EHR, its financial goals, staff fears regarding the change, and any politics in the office. When the office environment is properly primed, the technological aspects of EHR implementation will be less rocky.
Downs wonders if the RECs without a DOQ-IT background realize how much field work is required to ensure successful implementations. Having that past experience was “extremely important” as IFMC organized their REC, she says.
“As I’ve talked to some of our other non-QIO HITREC colleagues, I’m wondering with not having the DOQ-IT experience if they can fully appreciate the hard work that it takes in the field…,” she says. “We are putting our resources into our field staff who are going to be out there working one-on-one in these primary care offices.”
The meaningful use requirements call for providers to demonstrate how effectively they are using their systems, and doing so requires producing reports from the EHR. REACH’s Somplasky knows from her DOQ-IT experience that the first months of EHR reports typically are unreliable because staff are still learning the system.
To address this problem, Somplasky and her staff developed a close, sometimes contentious relationship with EHR vendors to improve reporting functionality. They will carry that experience forward into REACH’s work. Somplasky is already planning to work with vendors to improve meaningful use quality reporting.
DOQ-IT Tools Redeveloped
Several DOQ-IT tools developed by CMS and QIOs are being polished up and adapted for use in RECs.
CIMRO, the Nebraska QIO that developed Wide River Technology Extension Center, has passed all DOQ-IT tools to the Wide River REC staff, according to Greg Schieke, MBA, Wide River senior vice president.
The REC is developing its own unique tool kit, he says, but for much of the content, “We looked to DOQ-IT.” Wide River has adapted tools for outlining the functionality of EHRs, vendor contract negotiation and guidance, and workflow redesign.
The Wyoming/Montana and Iowa RECs are also redeveloping their DOQ-IT tools for use in their REC programs. Staff evaluated each tool to determine how it needs to be updated to meet new requirements.
One tool being adopted in the Iowa REC is an assessment of staff’s technological capabilities. This will help the REC determine how much training a physician office requires for the EHR implementation, and it helps identify the EHR champions who will be key to the project’s success, Swallow says. Other DOQ-IT tools planned for reuse in the Iowa REC are vendor selection tools, EHR goal setting tools, and patient education materials on EHRs, Hodges says.
RECs: More Complexity, More Support
While similar, DOQ-IT and the REC program do have some major differences. The DOQ-IT goal was to install an EHR system that would in general help improve care. The RECs must help providers achieve objectives specified in the meaningful use program, such as computerized physician order entry, which was not a feature of the DOQ-IT program.
The scope of the REC program is also much bigger. The DOQ-IT program required QIOs like CIMRO to implement EHRs in 5 percent of the state’s physician offices. For Nebraska, that amounted to 23 providers. But in the REC program, Nebraska’s Wide River TEC plans to help 1,200 primary care providers.
In Iowa, IFMC worked with nearly 120 physicians in DOQ-IT, but it hopes to implement an EHR in the offices of 1,200 providers through REC.
“We affectionately call the REC program DOQ-IT on steroids,” Downs says.
The REC program is also more aggressive, with the time frames for implementation more demanding than DOQ-IT, Downs says. Some providers had up to 18 months to work with the QIO in EHR implementations. The time allowed through REC will be much shorter as organizations scramble to become “meaningful users” and collect incentives beginning in 2011.
There is also more federal support for the REC program than with DOQ-IT, which was smaller in scale and targeted at early adopters.
The financial incentives, combined with the eventual penalties, should increase the number of providers willing to implement EHRs. Providers taking part in the DOQ-IT program received free services from the QIOs, but there were no bonus payments to offset the costs of purchasing and maintaining the systems.
Unlike the QIOs, some RECs are charging a fee for their services. But this could be a good thing for everyone, Urbanek says.
Because DOQ-IT services were free, some providers failed to make their IT projects a priority, which hampered the implementations. Paying a fee directly invests providers in the REC program and encourages an efficient, timely completion of the implementation, Urbanek says.
What Happened to DOQ-IT?
When the eighth scope of work ended in 2008, DOQ-IT officially ended as well. However, in the ninth scope of work, QIOs are taking the next step and are helping physicians optimize the use of their EHRs—for example, through preventative cancer screening initiatives.
With all the work put into DOQ-IT, it seems non-QIO RECs would want to benefit from the tools and the experience that resulted from it. Doing so could be difficult.
CMS never issued a final DOQ-IT report, and the EHR implementation materials and tools were removed from their original location on the Web shortly after the program ended.
However, the Office of the National Coordinator did tell RECs that it intended to partner with CMS and update all DOQ-IT materials to bring them in line with meaningful use. The plan was for the REC program’s umbrella organization, the Health Information Technology Research Center, to rework the DOQ-IT tools and make them available.
The tools may come too late for many RECs, however, which already are finalizing their business plans, implementation methods, and organizational structure with the expectation to start offering services this month.
RECs that are ready to hit the ground running need tools now, says Downs. They must rely on their own resources and resources offered from other RECs.
The research center is required to develop a private Web-based portal that all 60 RECs can use to share information and best practices. While the site is developed, RECs have been working in a communities of practice site—a preliminary version of the portal—where RECs have been exchanging DOQ-IT tools and other information, Somplasky says.
Confidence for the Work Ahead
Many QIOs considered the DOQ-IT program a success, and the REC program has a chance to be even more effective, Urbanek says. The funding, support, and buzz position the RECs to have an impact far beyond DOQ-IT.
The RECs expect the portion of their federal funding for direct provider assistance to be released by August 1. At that point, several RECs like REACH East and West in Pennsylvania expect to start implementing EHRs with providers. This is when the lessons of DOQ-IT will be fully put to use.
In addition to the tools and experience, DOQ-IT has given QIO RECs a sense of confidence that the job before them can be done. The REC program is a natural progression from DOQ-IT, combining the dual goals of implementing health IT and using it to improve the quality of care provided.
“DOQ-IT told us that we can successfully do this work, that we understand it, that we understand what the end goal is, that this is not about plopping technology into a practice,” Somplasky says. “It is about having practices re-examine the way they are providing care to patients and doing a more efficient, better job of that with our help.”