Healthcare Collaborative Spearheads Adoption of EHRs in Massachusetts
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.
Origins
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.
Pilot Projects
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.
