EMR Challenges Faced by RECs

I’ve been meaning to write a post linking to BobbyG’s blog for a while and just never got around to it. If you follow the comments on here, you’ll have seen many of BobbyG’s comments as well. The thing that first struck me about Bobby was his sincere and thoughtful comments on the challenges that the RECs face. Here’s some of his thoughts on REC Challenges:

  • Critics bemoan a lack of prior HIT deployment and QI experience among some REC awardees (as well as the heterogeneity of business models);
  • While 60 REC contracts have thus far been awarded, with the newly chartered RECs frantically ramping up to meet the rather compressed Stage One Meaningful Use incentive payment timelines, both the requisite Meaningful Use reporting criteria and the EHR (Electronic Health Record) certification regulations remain unresolved at this writing. The cart is seriously out in front of the horses in many respects;
  • The anticipated huge and short time-frame new demand for HIT installs may well overwhelm the capacity of HIT vendors, resulting in lengthy, problematic implementation queues (not to mention a severe shortage of qualified installation, training, and support personnel);
  • Notwithstanding that HHS is spending hundreds of millions of dollars on REC contracts, physicians and hospitals are not required to engage REC services in order to qualify for federal incentive payments. Consequently, RECs are having to spend significant time and money hawking their services (the polite term being “enrollment.” I did not know when I signed on that I would be required to do what amounts to hastily and minimally trained cold-call sales). Moreover, REC services are not fully subsidized, the upshot of which is often skeptical “we’ll pass” pushback, especially in light of the hyperbolic claims of virtually all major EHR vendors “guaranteeing” that their products will get the provider to MU (with the glossed-over disclaimer, well down in the fine print”When Used As Directed”);
    • At this writing, the aggregate Final Rule for MU criteria is still under HHS consideration, with myriad professional stakeholder groups arguing for relaxation of both the compressed compliance timelines and the all-or-nothing approach, countered by a broad array of equally vocal consumer/patient advocacy organizations arguing for MU criteria adoption “as-is” as set forth in the Interim Final Rule.

      I would have added another MU criterion: requireworking with the RECs as a condition of incentive money eligibility;

  • The relatively sparse per-provider federal REC funding may force the RECs to focus simply on assisting their client physicians with hitting the MU criteria in pursuit of the incentive reimbursements — to the practical exclusion of broader and more sustainable, internalized quality improvement efforts;
  • There is to be a “Health IT Research Center” funded by HHS and intended to gather relevant information on effective practices from a wide variety of sources across the country and help the Regional Extension Centers (RECs) collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support. The HITRC will build a virtual community of shared learning to advance best practices that support providers’ adoption and meaningful use of EHRs.”

    It is not even slated to be up and running until FY2012.

I think most of these points hit the nail on the head. RECs are in for some major challenges. It will be interesting to watch those that creatively confront those challenges and those that fold under the pressure of it all. I still stand by my opinion that they could be a tremendous force for good or bad. Considering there are so many RECs all over the US, I’m sure we’ll have plenty of both types.

About the author

John Lynn

John Lynn

John Lynn is the Founder of HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • Bobby’s definitely added a lot to the conversation on RECs. I feel for him and all those involved: it sounds like a high-stress initiative to be involved in, but one that could ulimately be very rewarding. I do hope the RECs (just like HITECH) are a success. Now that we may soon have accredited certifying bodies and products on the market, perhaps there job will get a little easier to manage.

  • Thanks for the cite, John. And, thank you, Michelle. Yes, it is indeed stressful. I have concerns that this thing may be set up to fail nationally.

    All I ever wanted to do was be a guitar player, LOL!

  • @John (&Bobby) I was rightly chided for not having read Bobby’s blog … so I spent time this past weekend doing that. Quite a bit to digest and I compliment Bobby on the logic and strategic perspectives presented in his blog.

    In many ways I agree with Bobby’s strategic perspectives … although I may differ with him on elements of aspects of execution. In any case … you picked an excellent intro of Bobby’s perspective by quoting his and Dr. Fortuna’s concerns for RECs posted on 10 May. During my reading I found his six concern items each worthy of thorough analysis and discussion. Something I think Bobby does a lot of already … but his points need a wider (and higher) audience.

    Later in Bobby’s post … he introduces what I think is one of Bobby’s main points and one I agree with 1000%: The constructive value of workflow analysis and design strengthens a practice’s ability to effectively deploy its EHR. In the section … “LEAN? THAT MAY BE OUT OF OUR SCOPE” … Bobby goes on to say …

    “I’d recommended that we consider deploying aspects of “lean methods” for workflow analysis and re-design… He didn’t say so explicitly, but his implication was clear: in light of our finite FTE resources … our necessarily circumscribed task will be to drive providers toward MU and the incentive money riding on it, period. … it should be equally clear that I don’t regard the MU goal contractual imperative as inexorably being at odds with the utility of lean re-design tactics. Neither do I buy the implicit, gauzy HHS assumption that clinicians hitting the MU targets amid the money chase constitutes focused, adequate, and lasting healthcare QI of the kind we are incontrovertibly in need of.”

    RIGHT ON BOBBY! I have the fear that in order for RECs to meet their milestones … they are going to be pressing practices achieve MU regardless of whether it improves the value of the medicine. HITECH is going to turn out to be analogous to “teaching the test”.

    I am not a Lean proponent … I prefer Theory of Constraints as the means to identify the primary constraint and improve output effectiveness. I recently finished “Velocity—Combining Lean, Six Sigma, and the Theory of Constraints to Achieve Breakthrough Performance”.

    Few RECs have the expertise to provide management consulting to gain the results needed … but whether Lean, TOC, or Six Sigma is employed separately or together by quality improvement experts … far more can be gained by improving work flow in a practice … increasing practice capacity and medical outcome quality. In this scenario an EHR magnifies the results and facilitates effective operations.

    Without full analysis and workflow improvement in the practice … then implementing an EHR and hoping to achieve MU will be limited and not sustained.

  • Bobby… When you wrote:

    “Critics bemoan a lack of prior HIT deployment and QI experience among some REC awardees (as well as the heterogeneity of business models)”

    … were you thinking about your neighbor to the west?

    Reading their Executive Director’s blog entry below makes me shudder … clueless. Totally clueless.

    “One of the most difficult aspects of this very challenging position is the sheer amount of uncertainty that accompanies much of the work. What gives me comfort in the midst of this uncertainty is that really, in all parts of our lives, we can’t know the future. What we can do is envision the best that is possible, encourage those around us to believe the same, and work really hard together to make it happen.”

  • @Don –

    First, thanks for your kind words about my blog post. At HealthInsight, we are not wedded to Lean or 6-Sigma or any QI ideology. We are equal opportunity thieves. We study and incorporate everything; human factors science, Theory of Constraints/Systems Thinking, Lean, TQM, Baldrige, etc, etc, etc.

    I more interested in stuff that works. I look at QI “methodologies” simply as tools in the toolkit.

    BTW, very interesting article here:


    On the subject of REC business models, I see a lot of them as set up to fail, and some of them specifically as thinly disguised shills for vendors/VARs, etc. Not gonna name names. Draw your own conclusions.

    Yeah, the CALHIPSO “blog.” LOL.

    Beyond “working really hard,” I want to work “really smart.”

  • Bobby… Captivating interview @ The Wrong Stuff. Thanks for posting.

    Could you explain your statement at the end of the fifth concern …

    “I would have added another MU criterion: require working with the RECs as a condition of incentive money eligibility;”

    Can you see why outsiders who already question what value a REC is providing them might not understand that statement? Many are already suspicious that ARRA HITECH is just an initiatvie to force practices to buy something that doesn’t work and create a revenue stream to software manufacturers at their expense. Literally.

    Lasty, I agree with you that if we are going to effectively deploy a national network of PCPs with EHRs we need to be spending twice as much as HITECH’s $18.4billion.
    Previously I provided this comparison to allow us to judge the commitment of USG toward really making EHR’s work. A year ago we launched Cash for Clunkers … originally a $1bil program that ran out of money in a week … so Congress gave it another $2bil. Total investment in this program that lasted only ONE MONTH … was $3bil. If we were going to have a CARS program for 5 year period … that would be $3bil x 12 x 5 = $180billion. That is 10x more than we are willing to invest in making EHR’s work. So which is more important?

  • @Don B –

    Could you explain your statement at the end of the fifth concern

    “I would have added another MU criterion: require working with the RECs as a condition of incentive money eligibility;”

    HHS is spending nearly a billion dollars on us RECs, yet we then have to go out and “recruit” providers, doing months of cold-call sales?

    That just opens the government up to right-wing charges that Obama is simply blindly throwing money around at cross-purposes.

    Many vendors and VARs see us as “competition,” which, in my view, is why we’re seeing some of the RECs doing “preferred EHR vendor” deals — basically trying to ensure that they don’t get cut out of the picture. Were I a viable vendor in a REC state that had excluded me, I might want to consider suing. It reeks of potential conflict-of-interest. Moreover, what about the true interest of the clinician? (Which is why we are officially and assiduously “vendor neutral.”)

    Why should a practice work with us? Because we have broad and deep expertise available, soup-to-nuts, at a pittance of the cost of private commercial consultants.

    It just begs the question of why RECs are even necessary. Maybe we’re not. Maybe docs can go it alone, or pay commercial consulting rates (that would eat up all their incentive money and then some). However, having decided that RECs are a value-adding thing, I fail to see the wisdom in making us optional.

    Many of the RECs are going to fail. They won’t even get to demo their implementation/adoption support chops, they will fail because of the recruiting resistance, and will have burned through most of their initial HHS funding, and will have to start laying people off (I won’t be allowing mold to accrue on my CV).

    To date, the leading REC in terms of recruitment is Qualis. Halfway through the expected recruitment period, they are at 9.2% of goal, notwithstanding a Code Red All-Hands-On-Deck recruitment effort.

  • Wow Bobby!! That last sentence is pretty startling. Definitely a HUGE uphill battle to do this recruitment.

    Of course, you know a quality comment like that is going to end up as a future post. Maybe you should become a full time blogger like me;-)

  • Thanks, John.

    I saw that you’d posted it.

    I visited with my own primary care doc the other day (semi-annual checkup). I’ve been trying to recruit him for the REC too. Three doc IM practice, potential $132,000 in MU incentive money, $54,000 in year one stage one. He’s been up on EHR since 2004 (EncounterPRO).

    He emphatically declines. “Too many government mandates; we have patients to care for.”


  • @Bobby … I understand. Yes, frustrating.

    Bad timing on all this right after Medicare took the 21% cut back to the beginning of June … and then will passage of the “kick the can down the road for 6 months” bill … CMS says it will take 3 months for them to go back and reprocess the claims for underpaid services.

    More and more practices are making the decision that Medicare is not a good client. All the mandates and EHR requirements for MU (whatever they turn out to be) along with penalties in 2015 are becoming too much.

    Thanks for your comments. I wanted to better understand the thoughts behind your statement that you would “require working with the RECs as a condition of incentive money eligibility”.

    Certainly the vendors and VARs view RECs as competition or unnecessary and uncontrolled interference in the business process… especially if the RECs think they will be able to secure below market EHR prices for software packages/services. Vendors and value added resellers have been in the business of selling their products and many RECs are not skilled at working with a customer to match their business and clinical operations to the right vendor and the right package.

    Some practices may avail themselves of the RECs services … some RECs better equipped to serve than others … yet other groups or PCP systems may rather hire a management consultant with EHR sourcing and deployment experience.

    There is a saying in business … “There is no value in free”. If a practice is paying the consultant for their services … then they know they are working for them. The RECs are being paid by the USG to meet milestones that lead to MU for the practices they enlist. There is going to be a clear effort in many RECs … especially those created solely to perform this function … to ignore other issues in the practice and push selection of an EHR package that may or may not match the practice’s needs and capabilities to sustain in hopes that the practice can reach MU.

    On June 14 John posted an item in his other blog EMR and EHR on the Analysis of REC Funding: http://www.emrandehr.com/2010/06/14/analysis-of-rec-funding/

    In that item recognized Marc Holland’s analysis of the resources RECs will have available.

    “He estimates in New York (where there are 2 RECs), they will have $4850 per physician available. The Ohio REC has $4750 per physician and the Michigan REC has $3300 per physician.

    Of course, this per physician rate is a little misleading since these RECs won’t get their entire grant if they don’t perform. So, depending on how they do, it could be even less.

    He also estimated based on the above numbers and the average cost for an EMR consultant that the RECs to break even would be able to provide “roughly two person-weeks in total – for contracting, for site planning, for training, for installation and first line post-implementation support.” Then, he suggested that wasn’t likely enough.“

    Bobby… I imagine that HealthInsight has looked at the numbers too. They are probably comparable to those reported above for Nevada and Utah. You are right that it would be extremely valuable to the practice to “consider deploying lean methods (or alternative- my thought) for workflow analysis and redesign. But as your support team member said: “Lean? That may be out of our scope?” … and there will be a drive at near all RECs to “drive providers toward MU and the incentive money riding on it, period.”

    A management consultant may have far more resources available to provide workflow analysis and redesign as a preliminary step to selecting and fielding the right EHR package which magnifies the gains made through the lean (or similar) effort.

    “Many RECs are going to fail”. I am afraid you may be right. You weren’t able to even recruit your own PCP. I can understand why you have made working through a REC as a condition of incentive money eligibility. Otherwise RECs must recruit practices using their slim initial cadre technical and management staffs to cold call prospective practices. Without a strong business base the resources aren’t going to be on staff to perform the work as an interface between the practice and the service providers. Since those providers see the REC as interference they will continue their own efforts to work direct with practices cutting the RECs out of the business.

    To those of us in business … inserting RECs into the middle of a market process just doesn’t clearly add value. While the services available on the HealthInsight HITREC webpage are more along the line a group practice manager would be interested in…

    •Initial readiness assessment
    •Workflow analysis
    •Tailored selection tools
    •Referrals to mentor clinics
    •Contract negotiation tools
    •Project management and implementation
    •Privacy and security best practice
    •Health information exchange assistance
    •Getting to Meaningful Use

    But other RECs list their services as the much thinner offering below … not providing many of the services itself but by referring the practice to vendors the REC has signed up but who the practice then must pay for.

    •Group purchasing rates for EHR systems
    •Subsidized prices for technical assistance
    •Access to “like” peer networks
    •Unbiased advice on which vendors and consultants to utilize.
    •Access to affordable technological tools,

    The challenges for the RECs are going to be huge.

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