Implementing an electronic health record (EHR) system is never easy. But maintaining one, especially in a medical practice with limited resources, is even harder, said authors of a new study(annfammed.org) published in the January/February issue of Annals of Family Medicine. But that's not news, according to one FP expert; it's a problem the AAFP has recognized -- and worked to rectify -- for years (see sidebar below).
In an article titled "Sustaining 'Meaningful Use' of Health Information Technology in Low-Resource Practices," researchers raised concerns about the inability of low-resource primary care practices to maintain their health IT investments -- and sustain meaningful use -- without financial and technical assistance.
The warning comes at a time when federal regulators and payers expect increasing functionality from health IT and expertise among physicians at the helm of these systems.
"Just as the more complex stages of meaningful use are beginning and the need for change management skills is increasing significantly, funding for the REC (regional extension center) program that could help these practices access the needed expertise is going away," said the authors.
- New research lays out the challenges low-resource practices face in maintaining their electronic health records and sustaining meaningful use of that technology.
- The more complex stages of meaningful use are beginning, just as support from health IT specialists at regional extension centers is ending.
- Low-resource practices that can't keep up with these challenges risk incurring Medicare penalties, missing out on incentive payments and providing lower-quality care.
"Our findings suggest that without ongoing support … low-resource practices may achieve stage one meaningful use only to fall by the wayside, resulting in an ever-widening 'digital divide' as better-resourced practices continue to increase the sophistication of their health IT operations," they said.
Meaningful Use Challenges
First, some background. The Office of the National Coordinator for Health IT (ONC) launched the REC program(www.healthit.gov) in 2009. The study authors noted that the "priority primary care physician" designation was created to "identify practices in particular need of assistance in overcoming barriers to health information technology adoption, implementation and attainment of meaningful use."
To offer that help, 62 RECs were established nationwide with federal funding from the American Recovery and Reinvestment Act. But those funds stopped flowing on Dec. 31, 2014.
In an interview with AAFP News, corresponding author and family physician Lee Green, M.D., M.P.H., hinted at the coming crisis. "Meaningful use of health IT is no one-time change. It's high maintenance over the long term. The resources have to be there, and one-time grants or short-term supports don't suffice," said Green, who is chair of the Department of Family Medicine at the University of Alberta in Edmonton and a former professor in the Department of Family Medicine at the University of Michigan in Ann Arbor.
AAFP Work Reflects Researchers' Concerns
The AAFP has long pushed for changes to help the most vulnerable family medicine practices succeed in the electronic health record meaningful use program, according to Steven Waldren, M.D., director of the AAFP's Alliance for eHealth Innovation.
Now, a study(annfammed.org) published in the January/February issue of Annals of Family Medicine has raised concerns about how such practices could maintain health IT and sustain meaningful use without financial and technical assistance. Key federal funding of regional extension centers meant to assist physicians ended on Dec. 31, 2014.
"The AAFP has always been supportive of the regional extension center program and its focus on low-resource practices. But we also warned from the beginning about the ramifications of short-term funding tied to the American Recovery and Reinvestment Act," he said. After all, this program "intentionally was created to become more rigorous over time," Waldren said.
Support for meaningful use exemptions for rural practices also has been high on the AAFP's advocacy list, and the Academy has made no secret of its strong disagreement with the program's "all-or-nothing" structure.
"If a practice does everything on the list but misses one measurement by 1 percent, they get nothing," said Waldren. "Adding some flexibility would mean practices that are trying to participate -- but are only one-half to three-quarters of the way there -- avoid a penalty, get a partial incentive payment and have some money to invest in moving forward," he added.
If these financial and operational issues are not resolved in a timely manner, "We'll lose some of our most essential practices serving vulnerable populations," said Green. "We'll either lose them functionally in that they won't be able to provide care at the level needed, or we'll lose them outright -- they will fail financially as they suffer penalties and miss incentive payments," he added.
Focus on Maintenance
For this study, Green and research team members from the School of Public Health at the University at Albany, State University of New York, and the Altarum Institute in Ann Arbor combined experiences with and qualitative data from two previous, unrelated Michigan-based projects.
One project involved consultations with federally qualified health centers to assist with health IT implementation. The other focused on the ONC-funded REC program of the Michigan Center for Effective IT Adoption. Concerns arose about maintenance of health IT in both projects.
"We believed these concerns had important and time-sensitive implications for U.S. health care policy," wrote the authors.
Researchers defined low-resource practices as primary care practices with "little or no internal professional management or information technology expertise and little or no access to external expertise in these areas."
They called the "management expertise deficit" a particular risk to low-resource practices and noted they required extensive education by outside health IT implementation specialists just to meet relatively easy meaningful use stage one requirements.
Little time was left for coaching "on change management or on the types of clinical process and quality improvement changes they (practices) will be expected to make in order to meet future stages of meaningful use," wrote the authors.
Staff training on technology issues also presents challenges, said the authors, because the vendor training staff members receive before a practice implements health IT is typically limited.
Stage two of meaningful use "will require much more sophisticated use of health IT, well beyond what they (practices) were trained to do in implementation," but low-resource practices don't have money for additional training time, said researchers.
"When support for the implementation specialists ends, low-resource practices not affiliated with larger, more influential organizations will not have agents to intercede with vendors on their behalf. Vendor capacity is already stretched, so larger customers are likely to soak up all the support available, leaving low-resource practices in the cold," wrote researchers.
"The initial idea for the RECs was that they would become self-sustaining through user fees. That appears to be unrealistic," said the authors. "The practices with the greatest need tend to have the least ability to pay."
According to researchers, the consequences for low-resource practices will escalate. Practices not in compliance with meaningful use face cuts in their Medicare payments and will miss out on incentive payments. They'll also fall behind other practices in the exchange of health information, reporting capabilities and quality improvement capabilities, all of which will inhibit their ability to earn quality incentive payments from private payers.
"The operational and financial consequences of falling behind in maintenance will mean lower quality care for the patients in areas these practices serve -- or, quite possibly, no care at all," concluded the authors.
Lee said low-resource practices would do well to affiliate with larger groups, organizations or health systems that could provide support. "The challenge is that many of these practices would if they could; they haven't because there isn't any such (opportunity) in their area," he added.
In addition, authors suggested making the REC program open-ended and adding health IT maintenance as a priority focus.
They also pointed out that Primary Care Associations(bphc.hrsa.gov) -- a nationwide network of state-based support organizations sponsored by the Health Resources and Services Administration -- could be called on to provide incremental resources to member practices at no charge.
Lee called it a "now or never" situation. "The right solution would be to make primary care practice more financially viable, but that's a huge system-wide undertaking in which the U.S. is far behind the curve," he said.
So we'll resort to a "duct tape" fix for now, said Lee. "But we'd better break out that roll of duct tape pretty fast."