Sustaining “Meaningful Use” of Health Information Technology in Low-Resource Practices

DISCUSSION

Our findings suggest that, without ongoing support addressing the themes identified above, low-resource practices may achieve Stage 1 meaningful use only to fall by the wayside, resulting in an ever-widening “digital divide” as better-resourced practices continue to increase the sophistication of their health IT operations. The advances in clinical processes expected for Stage 2 and Stage 3 meaningful use will strain both the technological expertise and management expertise of low-resource practices.

The management expertise deficit is a particular risk. Stage 1 (Table 2) was by definition the simplest and most straightforward of the stages of meaningful use, yet management in many practices struggled to understand the long list of detailed measures and how they applied to their practices. The implementation specialists needed to devote a major portion of their work to educating both practices and vendors about meaningful use. Stage 1 strongly emphasized implementation and documentation; thus, in many cases the practices did not actually need to make many clinical process changes to meet the requirements. Nevertheless, practices needed so much help in meeting Stage 1 requirements that they received relatively little coaching or education on change management or on the types of clinical process and quality improvement changes they will be expected to make in order to meet future stages of meaningful use. Yet just as the more complex stages of meaningful use are beginning and the need for change management skills is increasing significantly, funding for the REC program that could help these practices access the needed expertise is going away.

In terms of technology, staff training is a particular challenge. Vendors provide limited training before or during implementation. Stage 2 meaningful use (Table 3) will require much more sophisticated use of health IT, well beyond what they were trained to do in implementation, but low-resource practices are not able to purchase additional training time. As we said above, they are often not even able to train new staff adequately on existing technology as they lose trained staff through turnover.

When support for the implementation specialists ends, low-resource practices not affiliated with larger, more influential organizations will not have agents to intercede with vendors on their behalf. Vendor capacity is already stretched, so larger customers are likely to soak up all the support available, leaving low-resource practices in the cold.

Two resource issues underlie the challenges described above: financial and operational. Operationally, low-resource practices lack both the leverage with vendors and the managerial and technical expertise that larger group practices have. Financially, low-resource practices lack the funding to procure those operational elements from outside.

The implementation specialists from the RECs provided temporary operational resources (technical and managerial consultation, vendor intercession) at little or no financial cost to ensure the most vulnerable groups were able to meet the requirements, but without continued or alternative operational and financial support, many of these clinics will not be able to navigate the changes necessary to maintain the evolving demands of their health IT systems. As a result, these low-resource clinics will face Medicare downward payment adjustments of as much as 5% for noncompliance, inability to exchange health information between systems, limited reporting capability, missed incentive payments, and poor ability to support clinical quality improvement. The limitations on reporting and quality improvement capabilities will affect clinics’ ability to secure quality incentive payments from other payers as well. Since these clinics are often marginally financially viable to begin with, the Medicare payment and private-payer incentive losses will likely threaten their ability to remain open at all.

Solutions to the lack of health IT maintenance capacity in low-resource practices must address both their financial and operational needs. The initial idea for the RECs was that they would become self-sustaining through user fees. That appears to be unrealistic, however. The practices with the greatest need tend to have the least ability to pay.

One long-term solution would be to make the REC program, like the agricultural extension service program,¹⁹ an open-ended effort. The crucial component of maintenance could then be added to the existing implementation focus of the RECs. This approach would mean creation and support of a new set of long-term organizations, but has the advantage of broad reach across geography and circumstance. Recent recommendations from the President’s Council of Advisors on Science and Technology have supported this approach.²⁰

Another approach, at least for FQHCs and Community Health Centers, might be to provide the Primary Care Associations with incremental resources to provide the needed operational support at no cost to member practices. The Primary Care Associations are stable organizations and well positioned to address maintenance. Similarly, health systems that now provide operational and financial support to their own practices might be granted funding to take low-resource practices under their wings. Both of these approaches avoid creating new long-term entities, but may not help rural non-FQHC practices in areas of high need.

In some cases state Medicaid agencies have worked with RECs to obtain funding from CMS using Health Information Technology Implementation Advance Planning Documents.²¹ These funds have been used both to expand Stage 1 meaningful use support to providers outside the ONC priority provider designation (ie, specialists with high Medicaid patient volumes) and to help a limited number of providers in pursuit of Stage 2 meaningful use. The funding to date has done more to extend reach to additional providers than to support the continued engagement of services for maintenance. This mechanism, however, could be used to enable state Medicaid agencies to provide operational and financial support for maintenance. This approach, like others above, would take advantage of existing, stable organizations, and it would direct support to the practices most in need. Its disadvantage is that states vary quite widely in their support for their Medicaid programs. Practices in some states might benefit while those in other states receive little or no help.

Ultimately, any long-term stable solutions must address the operational and financial needs of low-resource primary care practices in general, and the additional needs of rural practices in particular. Absent that, the multifaceted challenge of health IT maintenance will almost inevitably overwhelm low-resource practices. The operational and financial consequences of falling behind in maintenance will mean lower quality care for the patients in areas these practices serve—or quite possibly no care at all.