More EHR REC Discussion

My previous post about the RECs possible failure has brought on some really in depth discussion on the topic of RECs and the challenges and opportunities they face. I encourage you to go and read all of the comments and join in on the conversation, but here’s a few of the in depth comments on that thread (since I know that many of you don’t read the comments):

Margarlit Gur-Arie, from On Health Care Technology, started the discussion with these comments:

1) Doctor’s aren’t moving as fast as the money is flowing
The money is NOT flowing independent of the docs’ movement. The money only flows AFTER a particular doc decides to “move”. RECs are operating on a P4P model.

2) The market already delivers on what RECs promise
The REC promises to touch every single small practice in rural and underserved areas. The market was never able to do so because the cost of selling to these docs was way to high. The RECs also promise to deliver about $5000 in consulting services to each provider practically for free and no strings attached. The market never in its wildest dreams offered anything like that.

3) “Preferred vendor lists” limit choice and free markets
Every consultant employed by a practice usually narrows the choices down based on research and knowledge of the market (some do it for kick-back). The RECs are going through a process to establish vendors capabilities and willingness to serve a particular State needs. The “free market” is just fine. The RECs are operating within that market. Not to mention that RECs only make recommendations. They will work with any vendor that a particular provider chooses.

4) RECs won’t get doctors to “meaningful use” fast enough
Fast enough for what? Incentives? I thought doing a good job at selecting and implementing a proper EHR is more important than a few thousand dollars handout. The goal is for the use to be meaningful to the practice. The rest will take care of itself.

5) The REC model leads to under-staffed, ephemeral entities
How so? Every start-up starts small. Some grow bigger and some die. This is exactly what will happen to these 62 start-ups. I’ve seen RECs hire and train pretty talented folks in rural areas. Salaries expectations are lower and with the current unemployment, it doesn’t seem to be such a monumental task to find good talent if you know where to look. I actually think that RECs are in a better position to find talent than national vendors.

Nothing is ever perfect, and as you know, I have been critical of many other “initiatives”, but I think that the REC concept is a valiant attempt to reduce disparities and bring technology and better health care to traditionally neglected populations and their equally neglected doctors. This is the #1 reason I want to see the RECs succeed.

My response was the following:

1. So, it’s poorly worded. The fact doctors are too slow to implement EMR means the RECs won’t be able to “perform” and won’t see money flowing.

2. Where did you get that RECs are touching “every single small practice in rural and underserved areas.” I’ve seen them mostly operating in big cities. Is there part of their mandate that I’m not remembering? $5000 in biased consulting is not a benefit to the market. Sure, some RECs are providing quality service, but many are playing the numbers game.

3. Another one that’s poorly worded. Of course the free market can still work. In fact, it will continue to work even if doctors select a bunch of unusable EMR. It will just take a long while for it to correct that mistake. The idea of a preferred vendor list is messed up though. Why would a doctor ever leave it up to another organization to go through the EMR vendor selection process for them. It’s an impossible task to try and have a preferred vendor list when you’re representing such a diverse population. There were much better options than what most have done. Props to the RECs who have indeed stayed vendor neutral and avoided even the appearance of impropriety.

4. If RECs focus too much on providing something meaningful to the practice they’ll miss their P4P goals and then they’ll end up leaving the doctors who they were trying to help all alone with no where to turn. Or doctors will have to start paying for the service they were told was going to be free.

5. Scaling up quality staff is an incredibly hard job in any industry. Getting quality staff to come and work at a REC that may or may not exist and therefore you may or may not have a job in a year is a challenge. It’s not impossible, but is a HUGE barrier to overcome.

Of course, I’m playing devil’s advocate above. I don’t think that EVERYTHING that the RECs are doing is terrible. In fact, there are some really sincere and smart people that I’ve met that are working at the RECs. BobbyG on this thread being one of them.

Maybe one of the bright spots of the RECs is that it’s at training ground for smart people like BobbyG to get experience and connections that will allow them to be some of the future leaders in really pushing forward EHR adoption. It just seems like the money could have accomplished the same thing and better spent other ways.

Margarlit then replied:

1) If the docs don’t adopt and the RECs don’t get money, the tax payers get to keep the funds. That is as it should be.

2) Part of the RECs mandate is to service underserved and rural populations. There are plenty underserved in big cities I guess, but the intent was not to serve Cardiologists in Beverly Hills. It is exclusively about Priority Primary Care Providers (small practice & underserved). If the RECs don’t go where they were directed to go, that’s a completely different story.
Why are you assuming that the consulting is biased? What possible incentive could a REC have to be biased? Unlike many “consultants”, they don’t make more money based on a physician’s EHR choice.

3) The population served is not as diverse as you may think. Primary Care docs in small practice – that’s all the RECs currently represent. I think you know as well as I do that the main reason for EHR failure is not really the software, but the lack of planning and change management and here is where the $5000 should be spent. There are happy users for any given EHR and there are miserable failures for the same software in the exact same type of clinic. This is what needs to be addressed.

4) Most RECs are signing docs on a yearly subscription basis. We all know that a PCP small practice can be successfully implemented and brought to Meaningful Use in 3 to 4 months start to end. I don’t see a problem here. MU is really not anything too terribly onerous for Stage 1.

5) Yes, scaling up with good talent is hard. But remember, John, some of the REC grants went to entities that were already staffed (NY is a good example), other went to Universities and others to Quality Improvement organizations. Very few are starting from scratch.

All that said, I don’t think this REC business is a walk in the park and I fully expect a big chunk of RECs to disappear after 2012. But the ones that survive will be very strong and very useful public resources.

As to the EHR vendor market, there are many benefits to the docs and their patients in areas where one EHR has a large presence, particularly if it is a decent product (see eCW in NY). To be honest, I am not too terribly concerned with how vendors fare. I am more concerned with enabling information exchange and quality improvements on behalf of patients. It is easier to accomplish that with a handful of vendors instead of a gazillion disparate systems, some of which will surely go under.
Yes, we could wait for the perfect EHR to come along, but I have a funny feeling it never will, so why not do the best we can with whatever is available now? We can always make adjustments as technology grows and improves.
Right now, if we are to put a dent in the 17% GDP consumed by health care, clinical information exchange is imperative, even if it’s not perfect.

I then posted this response:

My take on the bias of RECs is that if they have a preferred EHR vendor then by its very nature it’s biased. Plus, it’s creating a bias in what I consider to be the most important part of an EMR implementation process: the EMR software selection.

So, while I do agree with you that poor planning leads to some failures, I don’t think it’s the main cause of failure. I actually think selecting the right EMR and the process that’s used to select the right EMR is the key to a successful implementation.

Part of my reasoning for this is that selecting the right EMR and having the right process for selecting an EMR creates a clinical buy in that pays off in spades when you get into the dirty details of implementing an EMR. I think lack of clinical buy in is what leads to most EMR implementation failures and that’s often directly related to the EMR selection process.

I guess that’s why I get my pantyhose all bunched up when I see the EMR selection process tainted.

Certainly a doctor could get up and running and show meaningful use in 3-4 months, but that’s going to be the rare exception. Life and their practice gets in the way and makes it take much longer. Plus, these time frames start once the providers have firmly decided to make the jump. It’s that decision that slows the process more than anything.

I don’t care about the EHR vendor market either, but I do care that the best software is implemented by doctors since that is what will lead to the best patient care and patient outcomes. I don’t want the EMR vendors to be implemented just because they have great marketers.

Health information exchange is great, but until we have them using EMR’s it’s not even a possibility. A bunch of doctors implementing unusable EMR software which they hate will do more to hamper the widespread adoption of EMR software than anything else. This is why I’m so passionate about the best EMR software being implemented. Otherwise, it will take a lot longer to reach the health information exchange nirvana.

Margalit then answered:

The REC recommended list should be created through a stringent screening process which includes RFPs, demos and I’ve heard of one very large REC which has a usability lab just for this purpose. I would hardly call this process “tainted”, particularly since the screenings seem to be performed by practicing physicians.

To David’s point, the recommended list is just the beginning. Each individual practice is then expected to go through the usual vendor selection process and any and all certified EHRs will be considered. As David noted, RECs are obligated to work with any ONC certified EHR and the particular brand will not in any way affect their payments.

I think the RECs bring to the table resources for screening vendors that a solo practitioner does not have. They are also bringing with them certain strength in negotiating favorable contractual terms with recommended vendors. This must be a good thing for the docs.
Will this change the vendor landscape to a certain degree? Yes, I believe it will, but I also believe that the vendor landscape is in dire need of some changing.

I answered:

“The REC recommended list should be created through a stringent screening process”[emphasis mine]

The problem is that many of them haven’t been stringent.

Another “should” is the RECs working with a doctor that has any certified EHR. Of course they will work with them. They need their numbers. The question is what value will they provide that physician? Physicians who don’t use their preferred EHR vendor list won’t be motivated to work with the RECs. Not to mention the overall distrust of the RECs that I’ve seen from physicians.

I agree that they could have used the group buying power for some real good in negotiating favorable contract terms with an EHR vendor. I just wish that they’d actually asked the doctors whom they represent which EHR vendors they should negotiate with. This would have dramatically changed my view of RECs and what they could have offered.

Just remember that change doesn’t always mean a change for good. It could be a change to something worse. I learned that very early on when I had a boss who was less than favorable. Turned out he had his weaknesses, but his future replacement had even more. Fine lesson learned.

Of course, there were some comments in between as well that are definitely worth reading. Go and read the whole thread to see what I mean.

Who said I don’t write long posts on my blogs? lol

About the author

John Lynn

John Lynn

John Lynn is the Founder of, 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,, 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.


  • “Another “should” is the RECs working with a doctor that has any certified EHR. Of course they will work with them. They need their numbers. The question is what value will they provide that physician? Physicians who don’t use their preferred EHR vendor list won’t be motivated to work with the RECs.”

    WE don’t have a “preferred vendor list.’ Period. Lack of ARRA certification will be the only show-stopper.

  • “Plus, it’s creating a bias in what I consider to be the most important part of an EMR implementation process: the EMR software selection.”
    I completely disagree with this statement. In fact, I think EMR selection might be among the least important choices in the adoption process. Physician champions who understand change management and workflow re-design will be able to get to MU with any ARRA certified product.

  • BobbyG,
    I imagine ARRA certification is not even a show stopper at this point since we’re just starting to get the list of ONC-ATCB certified EHR.

  • SR,
    The best way to find a physician champion and help them manage the workflow re-design is to have them part of the EMR selection process. Them participating in the selection of the EMR and having buy in with the EMR that they helped select is what will make them a great physician champion.

  • John,
    I should note that I agree with your original premise: “Preferred” lists are in most cases inherently biased, if not corrupt. For the record our REC is completely neutral. I think being part of the selection process will certainly encourage physician champions, but the vendors aren’t really offering enough differentiation in product to consider this “the most important part of the implementation process.”
    In my view, provider education and end-to-end support will be RECs most valuable offering. While not every REC will have the talent/resources to see this through for every organization, I’m not sure where else providers can get reliable information. We are all so immersed in the Health IT world that it is easy to forget the average clinician is still in the dark.

  • SR,
    Props then to you and the Chicago REC for being completely neutral. Bobby and the Nevada/Utah REC is neutral as well. I support that approach.

    Your comment on their not being much differentiation between EMR vendors reminded me of this post I did: I’m sure you’ll enjoy it and hits on a similar vein and so I tend to agree with you that it’s hard to differentiate EMR vendors based on features.

    I still feel my point of physician champion still applies since for some reason during the EMR selection they grab on to some feature and become strong physician advocates of the EMR. Whether it really does differentiate it or not doesn’t matter. What matters is the physician seeing the value of implementing the EMR and turning the corner so they want to use it.

    I can see why you might not agree that it’s “the most important part of the implementation process.” Most or not, it’s still important in most cases.

    “I’m not sure where else providers can get reliable information.”
    I’d suggest and 😉

    In fact, on that note, I’m seriously close to just offering my e-Book on EMR selection for free. I make some money off it now, but to your point I think it might be useful to just get what I believe is a useful and neutral resource into more providers hands.

  • OK….one more thing, and I will let you guys sort it out on your own…. 🙂

    ‘“Preferred” lists are in most cases inherently biased, if not corrupt.”
    I would like to take serious issue with this statement (perhaps “preferred” is the incorrect term – should be screened or recommended).
    If a REC is not screening, evaluating and checking out vendors in advance, I think it is not properly discharging its responsibilities. I know “vendor neutral” sounds righteous, but “vendor blind” does not.

    If one of your docs “selects” a brand new, innovative GoldRushMD EHR, which is ONC certified (you could almost certify an Excel sheet if you tried hard enough) and the REC just helped the doc install that EHR, no questions asked, it would IMHO amount to dereliction of duty.
    A REC should be able to inform said physician that GoldRushMD has been in business for less than 12 months, has 5 clients which are the cousins of the owner, has 3 executives in the US and all 6 development and support FTEs are offshore and cash flow is nowhere to be found.
    If the doc still insists on this particular vendor, you of course provide all the help needed (as an independent consultant, I would walk away), but if he recoils in horror and asks what else is out there, the REC should provide a list of recommendations.

    Of course, you could go and do this research as you go along and docs come up with suggestions, or you can do it all upfront and call it a screened list, or a recommended list.

    Considering that most EHR vendors have pricing and contracts very advantageous to themselves, if you then take your screened/recommended list and negotiate group discounts and better terms for your physicians, you would be performing yet another service which is better performed upfront instead of a one off each time a physician selects something.

    You may call it bias, I would call it applying research and expertise for the benefit of your customers.

  • If a REC is not screening, evaluating and checking out vendors in advance, I think it is not properly discharging its responsibilities.”

    How doing that inexorably equates to having an a priori “preferred vendor list” escapes me. We do our (utterly thorough) vendor vetting in close analytical consultation with our providers. When EHR selection options winnow down to the necessary “short list,” it’s solely on the basis of the panoply of provider needs and goals.

    Moreover, your “GoldrushMD” hypothetical, given the Excel-sheet-hyperbole-to-make-a-point attributes you proffer, would never be a serious contender for ARRA certification in the first place, IMO (and even if it could, it would incontrovertibly fail all of the other functionality and usability criteria comprising the basis of which we advise).

    Not to say they don’t exist; they most certainly do. We’ve seen them all the way back to DOQ-IT days. Just that the bar has been raised WAY beyond the likes of them. Perhaps some RECs would fall for stuff like that, but I rather doubt it, and it would most certainly not happen in our shop.

  • Many large HIT companies have essentially “gone out of business” by failing outright, merging their product out of existence, sunsetting their product, or abandoning the market segment. There are no guarantees.

    In all areas, end-users continually weigh the risk/reward of “better mousetrap” new technology from start-ups vs. “nobody got fired buying IBM”, obsolete products from the incumbents.

  • I think we all agree that RECs should absolutely point out the challenges of a specific EMR vendor. That should definitely be encouraged. Doctors should be open to this type of frank discussion so that they can make a decision with as much information as possible. If RECs can and will provide that information to doctors, that will be fantastic.

    In that same vein RECs should be willing to also suggest to doctors that choosing an EMR vendor that could be acquired might be a bad choice as well. I know a lot of Misys users that are hating life since Allscripts acquired the nearly bankrupt company. Eclipsys users are next. So, even the large EMR vendors aren’t necessarily “safe.” RECs should be providing this information as well.

  • @Margalit … Please take a look at California’s CalHIPSO’s round 1 RFP selection of 8 vendors in 4 lines. CalHIPSO published their vendor list before either CCHIT or Drummond were named as ONC ATCBs … let alone before any of the 8 vendors were tested and deemed to be ONC certified.

  • To further this: some RECs have actually stopped accepting screening requests from EHR Vendors once their “Preferred” lists have been completed. This is a flash back to when the Certification process was so expensive that only big players could get in. The only difference is that this time it is Federally funded.
    DonB: And your are correct, this also took place here in Puerto Rico Ponce School of Medicine REC.

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