A profile of the HITArkansas REC and how it created successful relationships with physician practices and business lines that will make it sustainable.
HITArkansas, its state's only regional extension center (REC), it is part of the Arkansas Foundation for Medical Care (AFMC). In addition to the REC, AFMC supports the state Medicaid program through utilization review, provider relations services, and analytics. AFMC is also a federally designated quality improvement organization (QIO). AFMC was established more than 40 years ago and to many providers is the face of Medicaid in Arkansas. As a division of AFMC, the REC was poised for success from its inception 4 years ago. HITArkansas staff indicated they are not just "another consultant" offering services to providers, but instead they are part of an organization that has established itself as a trusted advisor to practices throughout the state. Arkansas has few integrated delivery systems, making provider trust crucial since providers are the decision-makers in their practices. Many REC staff also had experience working in private practices, further boosting their credibility from the practices' perspective. Arkansas presents challenges by being rural, having a high poverty rate, and having a large underserved population, but HITArkansas has nonetheless been successful in facilitating meaningful electronic health record (EHR) adoption throughout the state.
One key to HITArkansas' framing itself as a trusted advisor for physician practices was establishing good communication between it and the provider community. It hosts an eHealth Summit annually to provide a venue for interaction with an idea sharing among providers. The summit has become an opportunity for HITArkansas staff to get feedback on initiatives they are considering. For example, at the most recent eHealth Summit, HITArkansas vendor liaison Eldrina Easterly solicited feedback on implementing a state-level user's group for the top three to five vendors in Arkansas. Many eHealth Summit attendees supported this idea and seemed to be encouraged by the prospect of the meetings being facilitated by the REC staff members, who are seen as an advocate for practices. Mrs. Easterly's focus in the REC is establishing vendor relationships and leveraging them to help practices, allowing her to fulfill the practice advocate role more successfully. HITArkansas has established open avenues of communication among its staff. Despite field staff being scattered throughout the state, a staff meeting is held every week to make sure each staff member has an opportunity to share successes and challenges; every third week is an in-person meeting. HITArkansas has developed a robust array of tools and resources, largely conceptualized by field staff, identifying areas that would benefit from a tool or resource. Management and staff collaborate to determine the appropriateness of each tool or resource, the communications team translates the concept into reality, and then a complete and polished resource is distributed to all HITArkansas staff and posted on the HITArkansas Web portal. This collaboration among various components of AFMC has become an asset to all staff and the providers they serve.
Communication is imperative not only within HITArkansas, but within the larger AFMC organization. AFMC has successfully maintained separate QIO and REC (HITArkansas) divisions in part because clear policies dictate which services fall under which division, and in part because the divisions communicate seamlessly with each other. The QIO and the REC collaborate to provide Arkansas practices with the services and resources they need. Collaboration includes recurring operational meetings to help maintain the distinction between divisions and ensure that services are efficient and effective. AFMC's QIO quality specialists trained the EHR implementation specialists at the start of the REC program, illustrating how closely the two divisions work together to provide high-value services to providers. Currently, the REC provides services specific to Meaningful Use (MU) and EHR system implementation, whereas the QIO can help practices with managing workflows, interpreting EHR quality data, and developing quality improvement strategies. Both divisions are also able to align quality measurement metrics across different quality improvement initiatives as much as possible for providers, and they work to present quality improvement not as just a set of initiatives, but rather as a way of changing the practice to improve its care for patients. The QIO leverages the REC's field staff and works with them to disseminate quality-related resources and messaging to the practices. Pressing quality issues that move beyond specific clinical quality measurement and improvement (e.g., addressing disparities, improving health literacy, improving cultural competency) involve engaging local communities in addition to providers, which is what QIO quality specialists are skilled at doing. This framework provides ample space for both the QIO and the REC to support quality improvement.
HITArkansas assesses barriers to MU of EHRs and offers the services to address them. MU registration and communications training helps providers maintain the necessary MU documentation in a single repository, thereby easing the reporting burden and helping practices stay organized. HITArkansas leverages its experience with the EHR audit process to stress the importance of data collection and documentation. Although it does not designate preferred EHR vendors, HITArkansas highlights key points for practices to consider when selecting a vendor: data ownership agreements, disaster recovery plans, and how the EHR system will be updated.
HITArkansas uses DocRight, a software package offered at no cost to all RECs, but thus far used by only three. DocRight provides side-by-side comparisons of EHR vendors, including whether a vendor participates in the state's health information exchange (HIE). HITArkansas staff leverage DocRight's provider-specific updates on the status of the provider's interactions with prospective vendors, which allows them to be proactive with their clients while assisting them in the vendor selection process. HITArkansas sees the value of such assistance in vendor selection even though many Arkansas practices already have an EHR system, since HITArkansas observed that 17% of the practices they worked with have completely "ripped and replaced" their EHR systems. Furthermore, DocRight software can help identify what systems work best with specialists, which are so far largely unaffiliated with the REC.
Understanding that interoperability can be a barrier, HITArkansas has established a relationship with the Arkansas Office of Health Information Technology (OHIT), which leads the State Health Alliance for Records Exchange (SHARE), the state's HIE. SHARE allows patient information to be populated automatically in a patient's EHR, regardless of who provided the care, as long as (1) the rendering provider's EHR system is connected to SHARE and capable of consuming data and (2) the patient has not opted out of the program. The patient information is collected once, at the point of care, but can be queried often. SHARE also provides access to the state immunization registry gateway, supporting an MU objective. Access to SHARE does require a user access fee and often an EHR interface fee charged by the EHR vendor, and this is where the HITArkansas' relationship with OHIT becomes critical. HITArkansas provides the OHIT with information on EHR vendors with the highest provider volume in the area. In turn, the OHIT can negotiate with those vendors to bring down their interface fees, minimizing what could be a significant barrier to many practices. Given the close alignment of their goals, the OHIT and HITArkansas work closely together, particularly when marketing their respective products and services.
AFMC envisioned HITArkansas as a sustainable enterprise from its inception and planned accordingly. For example, HITArkansas has always charged providers for its services. This type of billing was new to AFMC, but they were able to incorporate it into their business practices to create a sustainable business model. Today HITArkansas can access billing and cost tracking, costs by service line, and other financial measures specific to its division of AFMC. Providers pay for a portion of their technical assistance fees upon contract execution with HITArkansas and the rest upon MU attestation. These charges are a barrier for some providers, but the EHR incentive payment helps practices overcome the concerns they may have about the fees. HITArkansas also conducts targeted outreach to providers who would most benefit from implementing an EHR system, to ensure EHR implementation is money well spent for the practices. Charging for services meant providers had "skin in the game" and were thus more likely to work collaboratively with HITArkansas and successfully attest to MU. The fees also provide revenues needed in the future for HITArkansas to continue to operate after the initial REC grant from the Office of the National Coordinator for Health IT (ONC) expires.
Another key to HITArkansas' growth was marketing. An already successful provider outreach model from AFMC was applied to the REC division, and HITArkansas was provided its own branding and logo distinct from AFMC. Having access to the AFMC communications staff is equivalent to having an in-house advertising agency that allows HITArkansas to develop a variety of materials that all have a similar look and feel. HITArkansas even has its own dedicated YouTube channel. It does not allow its tools and resources to remain static. For example, it has shifted from using stock photos in its materials to using photos of actual Arkansas practices receiving HITArkansas services to facilitate word-of-mouth promotion. Distribution of peer testimonials, Arkansas provider spotlights, and social media help illustrate to new providers that the benefits of signing up with HITArkansas are worth the cost.
HITArkansas has also begun to expand its service line. Understanding the need to remain viable after the EHR incentive program ends, HITArkansas has begun offering security risk analyses, which practices should perform at least yearly, and plans to expand them to include privacy issues and Health Information Portability and Accountability Act (HIPAA) compliance concerns, making the service line even more valuable to practices. In addition to being heavily branded, the tools and resources are kept behind a login with access granted only to clients of HITArkansas. Making these services exclusive in this way helps to maintain their value.
To maintain its status as a trusted advisor and to implement growth strategically, HITArkansas uses data available in Salesforce's customer relationship management tool. HITArkansas has a dedicated data manager to apply Salesforce reporting capabilities. For example, HITArkansas has access to security risk assessment statistics, EHR vendors the practices are using, practices' progress toward MU objectives, activities being performed and the hours billed for them, and HITArkansas's progress toward its own contractual goals. HITArkansas staff indicated that the Salesforce data are a valuable resource in managing their resources efficiently.
Planning for REC sustainability is ongoing. HITArkansas and AFMC are leveraging their relationships with state agencies (e.g., Medicaid); federally qualified health centers; and other RECs, where appropriate, for collaborations that can provide additional resources to support the REC. AFMC's investments in market research revealed that HITArkansas can increase its service to the provider community in areas such as patient-centered medical home transformation, alleviation of provider fatigue, and medical specialties. Demand in the provider community was surprising to AFMC, and it holds potential for REC sustainability and growth into the future.
HITArkansas has a valuable resource in its parent organization, AFMC, which has provided it with access to a variety of resources and connections to help them be successful. However, the key elements to HITArkansas's success are broader. A goal of any REC is to show practices how they can be transformed by capturing and using EHR data to improve quality of care and their own internal operations. HITArkansas staff use this same principle in their own operations. They identify providers who could most use their services, identify the services in demand, and measure how effective and efficient they are at providing solutions and disseminating them. Clear and consistent communication among internal and external stakeholders, as well as documentation and analyses of data, are methods for increasing efficiency in any area. As Nathan Ray, HITArkansas director, notes, "RECs have the knowledge and expertise to understand the issues their practices face relative to EHR implementation and optimization. They have a unique ability to apply best practices in these settings to give providers the tools and resources needed to overcome these EHR and practice challenges." Identifying and acting on opportunities for improvement and efficiency are goals not just for practices, but also for RECs nationwide.
For more information about HITArkansas, please visit http://www.hitarkansas.com/ContactUs.aspx [www.hitarkansas.com].