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May 10, 2010

Grant Money, Great Opportunity
By Alice Shepherd
For The Record
Vol. 22 No. 9 P. 10

Learn how three organizations plan to make the most out of the money they’ve received through the HITECH Act.

In March, the Office of the National Coordinator for Health Information Technology (ONC) announced the recipients of two grant programs under the HITECH Act, which seeks to improve healthcare delivery through an unprecedented investment in HIT. The State Health Information Exchange Cooperative Agreement Program grant supports states or state-designated entities in establishing health information exchange (HIE) capability among healthcare providers and hospitals in their jurisdictions. Fifty-six states, eligible territories, and state-designated entities received awards.

The Health Information Technology Extension Program grant establishes regional extension centers (RECs) to offer technical assistance, guidance, and information on best practices to support and accelerate healthcare providers’ efforts to become meaningful users of EHRs.

In this article, three grant recipients share their experiences, goals, and challenges.

Ohio Health Information Partnership
The nonprofit Ohio Health Information Partnership (OHIP) received $43 million, including $14.87 million to develop and implement a statewide HIE to lead the implementation and support of HIT throughout the state. The additional $28.5 million will support EHR implementations and help physicians and hospitals connect to the HIE.

Gov Ted Strickland and the Ohio General Assembly earmarked nongeneral revenue funding through the 2010-2011 state budget bill to pull down matching funds from the American Recovery and Reinvestment Act (ARRA), according to Carly Glick, communications assistant director of the Ohio Department of Insurance who currently acts as an OHIP spokesperson. Representatives from BioOhio (a nonprofit entity that has worked for more than 20 years to build and accelerate bioscience research, industry, and education), the Ohio Hospital Association, the Ohio State Medical Association, the Ohio Osteopathic Association, and the state of Ohio collaborated on the grant application.

“Three main funding streams support HIE technology and the adoption of electronic health records in Ohio,” explains Glick. “These include grants to promote health information technology planning and implementation cooperative agreements that will culminate in the implementation of a statewide HIE, funding to deploy an REC cooperative, and funding in the form of increased Medicare and Medicaid reimbursements to eligible physicians and hospitals that implement certified EHR software and meet federal meaningful use thresholds.”

OHIP will use some of the federal grant money to hire staff who will implement and manage the programs. Staff will include a CEO, a chief information officer, a communications officer, and other operational employees. The organization is posting job vacancies and selections will be made by a board (which has recently been expanded from five to 15 members) composed of members from the insurance, provider, business, and consumer communities.

Grant money will also be used to pay a vendor to implement the HIE; OHIP expects to choose the vendor by June. “Vendors have already responded to our request for information,” says Glick. “We’re currently reviewing their submissions to determine who will be eligible for the RFP [request for proposal] process. We are developing an RFP which will eventually translate into a vendor contract. One important criterion in the selection of a vendor will be its ability to provide high security. We’re currently evaluating our regional partners’ existing systems to see which of their security measures might translate into our objectives for a statewide system.”

Other grant monies will be used to build additional RECs. “We are collaborating with Ohio entities and providers who are already using HIT,” says Glick. “The ultimate goal is to have the 6,000 primary care providers adopting EHR systems, exchanging information to improve the quality and coordination of care, and achieving meaningful use over the next few years.”

OHIP does not intend to pay for providers’ EHR systems but will use a competitive process to select a group of preferred EHR vendors to offer software and services at a lower cost, as well as work through seven regional partners to provide implementation assistance. “We’ll have staff resources to help them,” says Glick. “The OHIP CEO will be very hands-on, out in the field, meeting with stakeholders, providers, and hospitals. Hospitals and practices can also count on assistance from the Ohio State Medical Association and the Ohio Hospital Association.”

To determine a regional rollout timeline, OHIP is currently working with regional partners, such as the Cleveland Clinic and HealthBridge, that are already connected to an HIE. “We’re gathering data on best practices so we can roll out a statewide HIE without reinventing the wheel,” says Glick.

Vendor selection and all other decisions will be made by the OHIP board, which will also monitor how the funds will be spent. The board does not conduct its meetings in public but shares its work on a public Web site. “Although OHIP is not a state agency, we intend to comply with state and federal financial reporting requirements,” says Glick. “For example, we’re required to develop a strategic and operational plan within six months of the award. The OHIP board and staff are working on developing the planning process.”

Within five years, OHIP hopes to have a fully operational statewide HIE. For now, the main challenge is getting providers on board. “We’re calling on stakeholders, such as the Ohio Hospital Association, the Ohio State Medical Association, and the Ohio Osteopathic Association, to work with their membership during the process,” says Glick. “Another challenge is to meet the ambitious timelines set by ARRA.”

Altarum Institute and the Michigan Center for Effective IT Adoption
The Ann Arbor-based Altarum Institute was awarded more than $19 million to serve as the lead agent in establishing Michigan’s REC, dubbed the Michigan Center for Effective IT Adoption (M-CEITA). It’s a partnership of 13 organizations, including the Michigan Public Health Institute, Michigan’s Quality Improvement Organization, the Michigan Primary Care Association, and the Michigan State Medical Society.

M-CEITA’s mission is to provide education, outreach, and technical assistance to improve the quality and value of healthcare delivery in Michigan. “As Michigan’s REC, M-CEITA will offer direct technical assistance to our provider community to accelerate EHR adoption and meaningful use,” says Daniel Armijo, MHSA, the institute’s director of information and technology strategies. “While we’ll eventually serve all of Michigan’s providers, our initial focus is on priority primary care providers as defined by the government. Out of about 17,000 primary care providers, we anticipate reaching 5,000 over the first two years of the grant. We’ll provide neutral, unbiased information to help providers navigate the complex EHR marketplace and CMS [the Centers for Medicare & Medicaid Services) incentive program. We’ll assist them throughout the entire process, from selecting and implementing an EHR product to demonstrating meaningful use and improving the quality of care.”

M-CEITA’s services will wrap around EHR vendor implementation services. “Until now, particularly small practice owners have been at a disadvantage in their dealings with EHR vendors because most are not experts in IT, practice redesign, or contract negotiations,” says Armijo. “Many providers lack the resources to thoroughly evaluate their options and make informed decisions. The REC will advocate on their behalf and level the playing field. We will create clear, concise resources; help providers assess their practices and redesign workflows; and negotiate group purchasing agreements. RECs have a unique advantage over group purchasing efforts that have historically been undertaken by hospitals or physician organizations. That is, we’ll never become wedded to a particular product or vendor. If a vendor’s implementation support is found lacking, we have the leverage to divert future demand to a different vendor.”

Some funding will pay salaries for a manager and local staff with process redesign and IT experience in each of nine medical trading areas across the state. “These teams will serve as local extension agents and be the providers’ connection to statewide support,” says Armijo. “We don’t want to duplicate services that are already available through physician organizations or subsidies from health systems. The effort will also have a significant workforce impact in both the creation of jobs and the skill enhancement of provider office staff using local community colleges.”

As the prime contractor, Altarum will make decisions in line with the ONC’s requirements. “Throughout the four-year grant, ONC will closely monitor the RECs through programmatic reporting and weekly phone conferences,” says Armijo. “While the ultimate authority is with the managing director, many decisions are going to be left up to subject matter experts. For example, we have experts on critical access hospitals who can make informed decisions because they understand the needs of that particular stakeholder group. All ARRA expenditures have a significantly increased level of transparency in reporting. In addition, broad stakeholder involvement from the local community will ensure transparency.”

Armijo anticipates one of the biggest challenges to be making the provider community aware of M-CEITA’s services and the overall benefits of widespread IT adoption. “That’s the biggest hurdle—getting providers to understand that this is not just about their individual practice,” he says. “Widespread EHR and HIE adoption can have a transformative impact on quality of care, patient safety, clinical and observational evidence, and patient engagement. That’s a significant leap of faith.”

While this flood of change is occurring, Armijo hopes M-CEITA can keep a low profile. “While transforming practices, we want our interactions to be minimally disruptive,” he says. “We offer guidance, tools, and market knowledge, but only provider office staff have the intricate knowledge of the workflows and the challenges of their practice. The decisions they make will determine how long it will take to see on-the-ground results. I’m very hopeful that we’ll see tangible changes in provider adoption and improvements in the quality of care within a year or two.”

Massachusetts e-Health Institute
Massachusetts received $13.4 million in a two-year contract to support EHR implementation for approximately 2,500 providers in small group practices and $10.6 million to support the operational planning and development of a statewide HIE. As the state’s REC, the Massachusetts e-Health Institute (MeHI), a division of the Massachusetts Technology Collaborative (MTC), will offer technical assistance, guidance, and best practices to speed HIT deployment across the state.

To apply for the ONC grants, as well as a workforce development grant, the MeHI relied on active stakeholder engagement during the development of the HIT Strategic Plan as well as from the MeHI’s two governing bodies: the Health Information Technology Council, which includes the state’s secretary of Health and Human Services and five private individuals with HIT expertise, and the MTC, which consists of private individuals representing various stakeholder groups.

Of the HIE grant, the MeHI wants to spend less than what was allocated by the ONC on operational planning by leveraging expertise in the private and public sectors. It hopes to accomplish this through the creation of multiple ad hoc workgroups that will be actively engaged with the MeHI in supporting the development of the HIE operational plan due by the end of August. At that point, the MeHI will issue an RFP for an entity that will build the HIE. There will be expenditures during the planning process, but the MeHI hopes the vast majority of funding available from the grant will go toward the implementation.

Part of the REC grant will flow to contractors known as implementation optimization organizations that will implement the EHRs. “We will oversee their work and offer value-added services which are available to all 20,000 providers in the commonwealth, not just the 2,500,” says MeHI Director Richard Shoup, PhD. “The remainder of the grant provides core funding of $500,000 a year for two years to support MeHI staffing and capabilities offered to providers through the REC. An additional $1 million may be available for years three and four as well.”

While the budget is managed and approved by the HIT Council and the MTC board, the MeHI/MTC is the fiscal and legal agent responsible for monitoring how the funds are spent. It also handles all reporting requirements mandated by the federal government.

The MeHI has filled leadership positions in its program management office and the REC and is actively recruiting for an HIE project manager. It is also planning to hire two clinical relationship managers who will serve as liaisons between the providers and the implementation organizations. Existing staff include an attorney who heads up legal and policy and an employee with substantial experience implementing systems who will supervise two clinical relationship managers.

“As a small organization, we rely heavily on stakeholders,” says Shoup. “We have created a governance structure that includes workgroups around HIE, RECs, privacy and security, quality reporting, consumer engagement, and workforce development. Those include thought leaders in the commonwealth who will inform the RECs, the HIE, and the HIT planning process on an ongoing basis. Because of Massachusetts’ conflict-of-interest laws, the workgroups can only make recommendations and have no decision-making authority. However, the recommendations will come before the HIT Council and the MTC board and will be given due deference by these decision makers because of the composition of the workgroups, which consist of national leaders with significant expertise and knowledge in the area of HIT.”

Shoup says the results are all about meaningful use. “In the past, the ROI [return on investment] of electronic health records was questioned because they were deployed inconsistently,” he says. “Meaningful use is going to change that. In 2011, the first set of meaningful use criteria will be measured. It’s going to take some time to get everybody up and running with the EHRs, but by 2015, we’ll see quantifiable results. For the HIE, we expect quantifiable results in three to five years.”

The main challenge in implementing 2,500 EHRs within two years is provider adoption. “To educate providers on the value of the HITECH funds, we are working closely with the Massachusetts Medical Society, the Massachusetts Hospital Association, Medicaid, and other key stakeholders to develop a common message,” says Shoup. “Another important message is to consumers, particularly to make them comfortable that their information is secure. This is not just about privacy and security. We’re creating a robust technical infrastructure and policy framework that will create trust.”

Another roadblock may be cost. The $5,000 direct incentives that the REC will receive for each of the 2,500 priority providers will be used to offset the implementation costs. To supplement the grant money, the  MeHI will also offer loan programs. It is also investigating the potential for a bonding authority to provide financial support to community hospitals and perhaps additional funding to speed up the implementation of the HIE.

Financial oversight from two boards, along with prescriptive ARRA reporting requirements, will ensure that the grant money is well spent, says Shoup, adding that the MTC, backed by a strong financial team, has audit controls in place. Meanwhile, the HIT Council will open its meetings to the public, and post minutes and presentations on its Web site, along with the HIT plan, REC and HIE minutes, and operational reports.

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.