The American Journal of Managed Care May 2011
Promoting Electronic Health Record Adoption Among Small Independent Primary Care Practices
Objectives: To describe the benefits and limitations of incentive arrangements used to engage small primary care practices to adopt electronic health records (EHRs).
Study Design: Retrospective review of program outreach efforts and EHR enrollment rates.
Methods: Comparison of benefits and limitations of various promotional strategies in addition to a city subsidy. Measures of enrollment progress include the mean number of outreach attempts, the mean number of days from first attempt to enrollment, and the enrollment yield. Selected practice demographics were collected for comparison purposes.
Results: Of 890 providers representing 217 practices who were eligible for the city subsidy, 37.7% enrolled, with a mean of 96.6 days from first attempt to enrollment and a mean of 10 outreach attempts. The offer for full payment of technical assistance fees and hardware yielded an additional 100 providers representing 43 practices, a 14.1% enrollment rate. This group also had the highest mean number of days from first attempt to enrollment (236.0 days) and the highest mean number of outreach attempts (22 attempts). The offer for a partial rebate had the lowest yield (a 6.2% enrollment rate), a mean of 169.3 days from first attempt to enrollment, and a mean number
of 19 outreach attempts.
Conclusions: Because of diverse needs and levels of awareness in the EHR adoption process, a flexible milestone-based process is needed to engage primary care providers. In particular, community influence and additional funding were necessary for increasing enrollment among providers in medically underserved neighborhoods. These providers also required persistent and numerous follow-up attempts. Because billions of dollars in federal aid are being offered, effective local recruitment strategies are needed to facilitate provider engagement to increase EHR adoption rates.
(Am J Manag Care. 2011;17(5):353-358)
Multiple methods are needed to engage primary care providers to adopt electronic health records.
- Beyond monetary incentives, educated outreach and recruitment support are needed to convince providers to adopt electronic health records.
- A contact relationship management tool or database is necessary for tracking progress and for coordinating recruitment efforts.
Before the passage of the American Recovery and Reinvestment Act of 2009, the New York City (New York) Department of Health and Mental Hygiene established the Primary Care Information Project (PCIP) to help implement EHRs and to assist providers in using information technology (IT) to improve healthcare. The city secured more than $60 million in public and private funding to subsidize the purchase and implementation of EHRs for 2000 independent primarycare providers. The PCIP focused on enrolling providers serving a 10% or greater threshold of Medicaid or uninsured patients. In addition, the PCIP extended extra attention to engage providers practicing in areas identified as District Public Health Offices (DPHOs). The DPHO areas are located in central Brooklyn, east and central Harlem, and the south Bronx and have the highest urban poverty concentrations, health problems among the population, and mortality rates.10
Despite significant resources offered by the city, primary care providers were not eager to adopt EHRs, and substantial effort was needed to generate interest and engagement among provider communities. Less than one-fourth of providers contacted by the PCIP had the knowledge or educational resources to make an informed decision about adopting EHRs.
Nationally, the Regional Extension Centers designated by the Office of the National Coordinator for Health Information Technology to assist providers in adoption and meaningful use of EHRs will be facing similar challenges. Provider engagement has been a substantial first hurdle in the path to adopting information systems. This communication detailsFebruary 2007 through June 2009 and the lessons learned to engage more than 1100 providers to adopt an EHR.
The PCIP focused recruitment efforts on primary care providers (eg, physicians, nurse practitioners, midwives, doctors of osteopathic medicine, and physician assistants in any of the specialties of internal medicine, family practice, pediatrics, geriatrics, or obstetrics and gynecology) practicing in New York City’s poorest neighborhoods or serving Medicaid and uninsured patients. Practices located within the 5 boroughs with at least 10% Medicaid or uninsured patients were eligible to receive software subsidies and support from the PCIP. The standard city subsidy program (PCIP standard program) covered software licensing costs for eClinicalWorks (Westborough, MA) and technical assistance for up to 2 years. Practices were responsible for purchasing hardware (eg, computers, printers, fax servers) and for covering infrastructure costs (eg, Internet service, IT consultant). A technical assistance fee of $4000 per full-time equivalent provider was also paid by the practice. The PCIP required the technical assistance fee as an indication of commitment to the implementation process. The technical assistance fee covered services from the PCIP on guidance with software integration, connection to electronic laboratory and pharmacy interfaces, community immunization registry, customized training and on-site sessions with experts in using the software for billing and effective documentation, and up to 10 coaching sessions with quality improvement specialists. Additional details of the PCIP standard program have been summarized in a previous communication.11
Because small practices did not generally belong to a single umbrella organization and were widely dispersed, partnering organizations were identified to enhance the engagement process or to “get the word out.” As a result, the following 4 programs were implemented to supplement the PCIP standard program: (1) community leadership, (2) health plan rebate, (3) Regional Health Information Organization incentive, and (4) private donation (Table 1). The community leadership used social networking to identify potential practices and leveraged provider-to-provider recommendations without additional monetary incentives. The health plan rebate was offered by a local health plan to practices with a minimum number of health plan members. Practices in this supplemental program would receive $2000 per full-time equivalent provider after implementing the EHR. The Regional Health Information Organization incentive was offered to practices located in Queens and sections of Brooklyn. Through the practice’s membership with the Regional Health Information Organization, they would receive $3400 per full-time equivalent provider before EHR adoption to help defray the technical assistance fee required by the PCIP standard program. The private donation was available only to practices in the DPHO areas and covered the costs of the hardware and technical assistance fee in full. The costs and support provided by the supplemental programs are summarized in Table 1.
A team of 4 staff members from the PCIP conducted outreach to recruit small medical practices, community health centers, and hospital ambulatory facilities. A customer relationship management tool, www.salesforce.com (The Landmark @ One Market, San Francisco, CA), was used to track communication with providers and to monitor progress toward enrollment. The PCIP obtained lists of providers from the American Medical Association and from health plan databases. Additional providers were identified by word of mouth from friends in the community, leveraging relations with physician leaders in New York City, and from ad hoc referrals. The PCIP generated interest in EHR adoption through education, software demonstrations, and e-mails containing program literature. Specific activities included announcements or articles in the PCIP partner newsletters, e-mail blasts to partner-affiliated provider networks, and in-person events. Follow-up activities were conducted by phone calls, e-mails, and facsimiles. The outreach team encouraged providers to participate in software demonstrations before enrollment.
Once engaged, the PCIP asked providers to submit an application by e-mail. The application form collected information on practice demographics, patient and payer mix, IT, and organizational readiness and goals for EHR adoption. The PCIP then reviewed applications and provided status updates within 3 days, followed by a phone call within 24 hours. Staff members sent contracts via e-mail to practices that met the minimum criteria for the city software subsidy. Providers were required to complete an IT assessment in preparation for implementation. Practices were given a deadline to submit a signed contract within 2 weeks. However, deadlines wereflexible and allowed leeway for time-intensive steps, such as hardware and funding procurement by the practice. The outreach team persisted with phone follow-up until the contracts were completed and payment was received.
The PCIP monitored each stage of the enrollment process using the customer relationship management tool. The tool alerted outreach team members of an individual practice’s progress from one step to the next in the application and agreement process. Practices that declined to enroll in the PCIP were categorized as “Decided Not to Sign Up”; others who did not move on to enrollment within 3 months were categorized as “Aged.” For both categories, no additional phone follow-up was conducted by the PCIP. Providers who delayed enrollment because of various constraints were categorized as “On Hold,” and PCIP staff established a time frame in which to reinitiate contact.
Staff members generated descriptive statistics to assess the effect of each strategy on improving enrollment. Fewer than 10 practices qualified for more than 1 of 4 supplemental programs; analysis considered only the most recent supplemental program to which a practice was exposed. The mean number of outreach attempts, the mean number of days from first attempt to enrollment, and the enrollment yield were calculated. Selected practice demographics were collected for comparison. Descriptive statistics of enrollment yield, the mean number of outreach attempts, and themean number of days from first attempt to enrollment were limited to federally qualified health centers or small independent practices.
Of 30,000 providers estimated to practice in New York City, the PCIP contacted 7263 potentially eligible primary care providers. Of those, 4379 were identified as eligible for the PCIP standard program and were affiliated with a federally qualified health center or a small practice. Roughly 25% of eligible providers enrolled by April 2009, and the remaining providers decided not to sign up, became an aged application, or were put on hold.
Through the PCIP standard program, 890 providers representing 217 independent practices joined, an enrollment yield of 37.7%. On average, these practices took 96.6 days to sign an agreement and 10 outreach attempts (including phone, e-mail, and facsimile). The average practice that enrolled through the PCIP standard program had 4.1 providers, with a patient population of 44.6% Medicaid and 8.6% uninsured (Table 2).
An additional 48 providers representing 24 practices joined through the community leadership process. These practices had the highest mean proportion of Medicaid insured patients (73.8%) and were similar in practice size (2 providersper practice) to the other supplemental subsidy programs.
The health plan rebate had the fewest additional providers join (33 providers representing 18 practices), with the lowest enrollment yield of 6.2% from an eligible pool of 529 providers. The Regional Health Information Organization incentive brought in more providers (51 representing 18 practices) and required a little less effort by the outreach team. The private donation brought in an additional 100 providers representing 43 practices but required the most recruitment effort and the longest lag time for signing an agreement. Statistics for the number of attempts and the time to enrollment across the programs are summarized in Table 2.
Within the first 28 months, the PCIP assisted 1122 providers representing 320 independent primary care practices to adopt EHRs. Although the PCIP offered various supplemental incentives, persuading physicians to implement EHRs was challenging and labor intensive. Summarized herein are experiences of the PCIP with provider engagement and recruitment strategies for EHR adoption.
Make Use of the Customer Relationship Management Tool. The strategies developed by the PCIP were refined based on available call logs and communication activities entered into the customer relationship management tool www. salesforce.com. These data permitted the staff to continually assess their efforts through the early stages of the outreach process and to identify needs for follow-up, as well as to coordinate communication efforts to avoid repeated or conflicting messages.