Speranza Avram, the CEO of CalHIPSO, the largest of the 62 federally designated regional extension centers, has spent three years helping physicians in small groups to achieve meaningful use. Going forward, being able to continue to help providers beyond the end of this year will mean developing new models of sustainability.

The Oakland, Calif.-based California Health Information Partnership & Services Organization, CalHIPSO, is the largest of the 62 federally designated regional extension centers (RECs), serving more than 6,100 providers eligible for stimulus support under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act.

Working with providers in 56 of California’s 58 counties, CalHIPSO works with community clinics and federally qualified health clinics, rural hospitals, public hospitals, and other patient care entities, including very small physician practices. Like all of the RECs, CalHIPSO has been operating through a three-year grant; all the REC grants run from Jan. 1 2011 through Jan. 1 2014, after which all the RECs will need to operate based on new business and governance models. CalHIPSO’s grant has been for $35 million, based on the same model on which all the RECs have received their grants, with the Office of the National Coordinator for Health Information Technology (ONC) providing grants at a level of approximately $5,000 per assisted eligible physician/provider.

What’s more, CalHIPSO does its work as a statewide REC in the context of professional networking, keeping its own staff lean at 18 employees, and subcontracting some of the core technical work to local extension centers.

One area of particularly exciting promise: CalHIPSO has been developing analytics capabilities for its physicians and other providers, and has been working with the Emeryville, Calif.-based MedeAnalytics to develop the IT foundations for that work.

Speranza Avram, CalHIPSO’s CEO, spoke recently with HCI Editor-in-Chief Mark Hagland regarding her organization’s work helping physicians and other providers to implement electronic health records (EHRs) and help them to then leverage the capabilities of their EHRs for performance improvement and population health work. Below are excerpts from that interview.

Most of your participating organizations are small medical groups?

Yes, and also community health centers, and public hospitals. Not surprisingly, there continue to be some challenges with EHR adoption. My chief quality officer and I recently identified some core challenges, including the following: difficulty accessing and running in a timely way the reports from EHRs to assess and monitor their meaningful use work; meeting certain meaningful use objectives such as providing after-visit summaries to 50 percent of patients, documenting tobacco use, etc., objectives that to be met require complicated changes to physician workflows; and understanding some of the complex requirements of the EHR incentive program, including meeting the eligibility requirements for the Medicaid EHR support program.

Speranza Avram

Tell me about some of the vendor platform issues you have to deal with.

We love working with our vendor partners. But of course, they’re all on different systems. The top two EHR vendors we work with are NextGen and eClinicalWorks, but there are literally dozens of them in total. So that’s one of the challenges. Another challenge is that many clinics adopted EHRs two, three, four years ago, and they’re having to upgrade because of meaningful use, and often, there’s no standardization even within their own organizations, because of intensive customizations that they’ve engaged in in the past. So in many cases, the upgrades have been even more complicated than just buying a new EHR. And MediCal [MediCal is California’s Medicaid program] providers, which most of ours are, even if they were ready, could not have attested until September. About 65-70 percent are attesting under the Medicaid program, and the rest are attesting under Medicare. So the attestation is going to happen early this year.

Where do the analytics come in, in relation to this work?

In our pilot project with MedeAnalytics, we discovered that data analytics aren’t really designed to help providers with meaningful use, because meaningful use really is a straightforward data collection process; the analytics really come after achieving meaningful use, because they support providers under value-based payment. So, first, you need the foundation, you have to have the software, and demonstrate that you can use it meaningfully, to get the payments. Now, you’re ready to participate in any kind of value-based payment, whether ACO [accountable care organization], PCMH [patient-centered medical home], PQRS [the federal Physician Quality Reporting System], or value-based purchasing.

So the value of data analytics, and the way we’re approaching our data analytics efforts, is to make it possible for the provider to collect the data they need, and then participate in whatever value-based payment program they’re involved in. So one of the things we did early on with MedeAnalytics and with our team here, was to look at the various data elements available to our team here, and we cross-referenced those with the various programs providers are participating in. One example is monitoring the hemoglobin a1c value for diabetics, which is an element in so many of the programs [that measure clinical outcomes]. It helps the provider understand what’s going on with that measure. That having been said, many of our providers are still getting ready with the basics of meaningful use.

So you could help them extract data on just about any broadly tracked measure?

We’re not quite ready for launch yet, we’ll be launching in about a month. But, no surprise to anybody, data analytics is expensive to do in a onesie-twosie setting; that’s why it hasn’t been done, right? So you have to scale it. And how do you do that? So you say, for this price, you’re going to be able to get this much data. So your best value is the lunch special, where you get choices A and B, but if you go totally a la carte, it will cost you more. So you get the most value by staying within certain parameters, right? So that’s how we make data analytics affordable for them. And our small-clinic market is not quite ready to put data analytics into their operations today. But there are business aggregators—IPAs, health plans, particularly the public health plans, larger hospital systems that might want to work with these clinics. So we’re helping these help sponsor some of these costs, to help these physicians participate. Because physicians are kind of a “show me” group, so until they can see the potential rewards, they’re going to be a bit reluctant to start participating.

And you’re working in other areas as well, right?

Yes. So the biggest question on many people’s minds is, what is the sustainability plan for regional extension centers in general, and for CalHIPSO in particular? So in October, we hired Karynsue Rose-Thomas, our chief of business development, who used to be the director of the REC in Orange County. She understands the needs of the provider community, and has been helping us to develop a set of products and services that we’re getting ready to launch. We actually have three strategies, as outlined on our website (www.calhipso.org). But, per sustainability, there are three big categories of strategies. The first strategy is data analytics, as we’ve discussed.

The second strategy is to provide is fee-based adoption services. What does that mean? It means that right now, as the REC, we help providers install EHRs to get to meaningful use; and we’re able to offer that for little or no money, because we receive the federal grant that subsidizes that work. And we recognize that that work continues, because the providers have to go through stage two; and many specialists don’t qualify. So we’re going to be offering HealthE Services—a menu of different services that providers can purchase. And we’re trying to keep the rates affordable; and we’ll be working with our partners, our local extension centers, our own staff, and we’ll be marketing a line of business—essentially, health information technology adoption services.

The third strategy is what we call business partnerships; we’ve got 8,500 providers, and they keep joining. And that’s a market aggregation, isn’t it? So we have, not surprisingly, many different kinds of companies saying, could we partner with you, on a revenue-sharing basis? So we are evaluating those opportunities on a case-by-case basis, to determine which of those would meet our members’ needs, where they would provide the services. And the first partnership will be with ClearData, a company that offers privacy and security services. And that’s something that our providers need to get to stage 1 of meaningful use and beyond; and it’s a unique enough service; and we’ll be offering that to our members and others. So that’s one example of a business partnership; and we’ll be offering others as well in the future.

So what will happen in the next year?

We have two big goals in the next year. Goal number one is to get as many of our 6,187 providers to meaningful use, Stage 1. So we’re starting the year with having to help nearly 5,000. And what’s interesting is that 1,200 is as many has some RECs have in their entire networks. So let’s get as many of those 6,187 providers to stage 1 MU within the year—and my goal, frankly, is 100 percent. And our second goal is to transition CalHIPSO from a federal grant-funded organization to a services provider that can help them be successful in the new healthcare environment. So we want to pivot ourselves within a year to the new situation. We have one year before the federal funding ends, on January 1, 2014.

Those are quite ambitious goals.

Well, it’s the job we’ve been given. We’re the largest state in the nation, so we have the largest REC in the nation. And we recognize that adoption and meaningful use are a bit challenging, so we’re starting the year with big goals. At the same time, we’ve been given the charge by the ONC of developing sustainability beyond the grant. We received $35 million; that goes a ways, but given that there are 35 million Californians, in that context, it’s not that large. The ONC created a formula with a per-provider cap, around $5,000. So the more providers you have, the more money you get. And part of our responsibility has been, for the past three years, to manage that money well. But everything we’ve been told by the ONC is, do not expect an extension, this is stimulus funding.

And, given the environment in Washington, the chance of getting more money are probably small, correct?

Probably. But there has been a tendency to look back at the meaningful use program and say, the standards aren’t enough, or the accomplishments aren’t high enough; but my response to that, as someone who’s living and breathing this every day, is, you have to meet the doctors where they are.

Meaningful use really has been a success, in that sense.

Yes, it has created a tipping point. It created the critical mass; five years ago, you were still talking to physicians who were doubting whether they would ever get an EHR. Now it’s not whether, it’s when. Or they’ll retire. But no one is believing that they’ll be able to practice medicine in a non-electronic environment. And I say when folks come to work at CalHIPSO, you know what? The goals are very, very clear here. I call the success measures breathtakingly direct, we know based on the numbers.

And many of our readers will be executives in those “aggregator” organizations you discussed, like hospital systems.

Yes, and it’s interesting, because I believe California is one of three states (I believe the others are Texas and New York) that still forbid direct physician employment. And the center of our universe is the physician or provider; and we’re enabling their choice. If they want to be able to affiliate and build their capacity, that’s their choice as well.

So what lessons are you learning?

One of the things we’re increasingly observing, per the future, is, from the provider perspective, the ideal universe is that when patients get care in their office or another physician’s office, or at a hospital, regardless of where the patient receives care, the clinical information is put in a place where providers can use that appropriately. What we’re seeing in our marketplace is that the business rationale is not quite there yet to support that. But who’s buying the HIE [health information exchange] companies? It’s the payers! Every time I turn around, there’s another payer buying an HIE company. Why? Because they want that information. And we are interested in working with payers. But what I’m seeing is that the leverage is moving to the payer community, and they’re buying HIEs to basically manage the flow of information that they need to do their jobs. So the industry’s not quite there yet, and that makes our jobs a little bit harder. But we’ll be moving forward.