The Massachusetts eHealth Collaborative (MAeHC) is a nonprofit
company registered in Massachusetts, launched in September
2004 by a coalition of 34 leading Massachusetts-based healthcare
organizations representing each part of the healthcare delivery
value chain. MAeHC’s mission is to facilitate the ubiquitous adoption
of electronic health records (EHRs) with embedded decision support
and health information exchange (HIE) in the Commonwealth of
Massachusetts. Our strategy is to fund pilot projects in three communities
to evaluate and (hopefully) demonstrate the value of ubiquitous
adoption of such systems, approaches to overcoming barriers to adoption
and models for rolling out a statewide program.
The inspiration for MAeHC has two sources. First, the Massachusetts
Chapter of the American College of Physicians (ACP), then led by Dr.
Allan Goroll, made its top priority the ubiquitous adoption of EHRs in
Massachusetts among primary care physicians. They devised a project
plan called MA-SAFE, authored by Dr. David Bates of Brigham &
Women’s Hospital, that outlined what such a program would entail.
The second key source behind the creation of MAeHC is Blue Cross
Blue Shield of Massachusetts (BCBSMA),which made a $50 million
commitment to launch and fund the MAeHC pilot projects. The BCBSMA
vision behind this significant financial investment is to bring
together all key healthcare stakeholders to create tractable solutions
to the system problems that plague healthcare delivery in the U.S.
The ACP and BCBSMA visions merged in a unified vision of
making a large financial investment in a project to demonstrate
the value of such systems and identify a model that is replicable
and sustainable. The aim of the project is to demonstrate the “winwin”
among all stakeholders to catalyze the statewide rollout.
The MAeHC pilot projects began with an invitation in December
2004 to any community in Massachusetts to apply to become
“wired” for healthcare.We received 35 applications from across
the state and chose three communities to be pilot sites: Brockton,
Newburyport and North Adams. Our main evaluation criteria were:
- Demonstration of community and physician leadership;
- Some experience in using IT to improve care; and
- High “capture” of medical encounters.
While we were only able to fund three applications for the pilot
period, there were many excellent, fundable applications, which
we see as a call to action to move beyond the pilot projects to the
rest of the state as quickly as possible.
Our three pilot communities together comprise roughly 450
physicians, plus another 125 “mid-level” clinicians. They collectively
take care of approximately 500,000 patients in more than 200
practice settings. These physicians are affiliated with four acute
care hospitals across the three communities.
The pilot projects have four key activities, as depicted in Figure 1.
Starting from the bottom up, the MAeHC pilot projects are subsidizing
the systems, training and support for outfitting all 450
physicians with EHRs. Through a mix of vendors and our own
staff, MAeHC is providing pre-implementation training, work flow
design and project management services to each of the practices.
We have validated four EHR systems – Allscripts, eClinicalWorks,
General Electric and NextGen – which we will be deploying in the
three communities. Physicians were given considerable choice in
order to maximize adoption. They were allowed to choose: 1)
which of the four EHR systems they would like; 2) whether they
would also like the integrated practice management system that accompanies the EHR; and 3) if they would like to have a client/server deployment or a remote ASP deployment.
We guided the decision making through a series of community
vendor fairs that allowed the physicians to make side-by-side comparisons
of systems going through the same scripts, but also
allowed the opportunity for individual question and answer.
The second phase of the project is the HIE,which will connect the
stand-alone EHR systems. Each community will have its own closed
network with which authorized users (physicians and their staff) can
exchange patient data in real time for treatment purposes. The HIEs
will allow other important functions, such as electronic referrals
tracking, automated electronic results delivery (lab/path/microbiology
results, radiology results, inpatient/ED discharge summaries, etc.)
and secure messaging. Each HIE will include a patient portal, though
the functionality of this will likely vary across the communities.
The evaluation component of the project is enormously important
because these are pilot projects from which we want to derive lessons
to inform our (and the rest of country’s) longer-term strategies. Our
evaluation will cover adoption, replicability and value.We will glean
best practices related to identifying and overcoming barriers to adoption,
as well as understanding what the best models will be going forward
to extend the project to the rest of the state. Regarding value,we
are examining economic issues such as impact on office efficiency, as
well as community-level efficiencies.We are creating a data warehouse
that will electronically extract and aggregate clinical data from
the deployed EHRs for quality and outcomes measurement.
Finally, we have established a governance model in each community.
Each community has a steering committee representing a cross
section of the key healthcare stakeholders in the community with
whom MAeHC is working collaboratively to make key decisions to
guide the project. These committees have become increasingly important
as we have begun to set policies and “rules of the road” regarding
communitywide privacy, security standards and HIE functionality.
The latter is particularly important because, for these HIEs to sustain
themselves beyond the pilot period,we need to determine the product
and service offerings that will offer a real value proposition on
market terms to the healthcare participants in the community.
As of October 2006,we are approximately 25 percent completed
with the program. About 40 practices comprising roughly 100 physicians
are now live on their EHR systems. One community will go live
with their HIE by the end of 2006. All of the EHR and HIE implementations
in all three communities will be completed by July 2007.
Early Lessons Learned
While it is still very early in the project, some early lessons have
emerged from our experience. First,we believe communitywide
deployment of EHRs can be accomplished if done collaboratively with
all of the key stakeholders in the community. Establishing this collaborative
program, though somewhat time-intensive, will have lasting
payoffs in terms of higher adoption and community sustainability.
Second, affordability is not the only barrier to widespread adoption
of these systems, and often, not even the most important barrier.
The “soft costs” aligned with project and change management also
weigh heavily in the decision making, and there are no easily available
services on the market to address this type of demand.
Third, clinical IT adoption should not be “left to the market,” as
there are still negative externalities associated with such a laissezfaire
approach. For example, the real value from EHRs will come from
successful implementations that use sophisticated products (e.g.,
those approved by the Certification Commission on Health IT) and
fully implement all the features of these products in the office work
flow. The market is replete with rudimentary systems that do not
offer the quality and safety features built into the more sophisticated
systems. Too many practices do not fully implement sophisticated systems,
so they don’t get the benefits of the higherlevel
functions these systems offer. Lastly, without
a coordinated program, individual purchasers
will not include interoperability with
other existing systems in their decision-making
criteria, even though health information
exchange based on such interoperability is
where much of the value to society lies.
MAeHC is developing a proposal to raise the
money necessary to extend the EHR deployment
program to the rest of the state. The guiding
principles behind the proposal are that it must
be fair share, so those who pay should get value
in proportion to their payment; and it must be
limited in time, so it motivates the market to
move more than it would otherwise. As the pilot
projects yield more and better information,we
will refine the program to take into account
these lessons learned.