There is a critical element in the American Recovery and Reinvestment Act (ARRA) that targets funds for Federally-Qualified Community Health Centers (FQHCs). An FQHC is an organization defined by the Medicare and Medicaid statutes that receives funding under Section 330 of the Public Health Service Act. FQHCs provide primary care services for all age groups and provide preventive health services on site to some of the country's most vulnerable populations, and they are an important part of this country's primary care delivery system. Among services that FQHCs must provide directly (or by arrangement with another provider) include: dental services, mental health and substance abuse services, transportation services necessary for adequate patient care, hospital and specialty care. There are more than 16 million Americans who are served by FQHCs.
Some of the $1.5 billion in infrastructure funding from the HITECH section of the ARRA may be used for “acquisition of Health Information Technology (HIT) systems” and all FQHCs are eligible for these funds. This funding can be used to support the acquisition of HIT in a number of ways including construction, renovation and required equipment. There will be additional grant funds through the Department of Health and Human Services (HHS) Office of the National Coordinator for Health Information Technology (ONCHIT). FQHC’s would be paid up to 85 percent of “allowable costs” (as determined by HHS) for the acquisition, implementation (including training), upgrade, maintenance, and use of a “certified electronic health record” system (certified by the Certification Commission for Health Information Technology–CCHIT).
But there is a problem: the ARRA funds are terrific if you belong to CCHIT-land, but what if you don’t?
Let me explain. I am a clinician at one of finest HIV/AIDS clinics in the Unites States, located within the San Francisco General Hospital. We are at the epicenter of the AIDS epidemic. I am also the director of our Health Informatics Group. We have an EHR software system developed and refined by the clinicians and our technology leaders (including a personal health record for our patients ) that has provided the backbone for documentation of care, for care coordination and planning, and for our cutting edge research activities since April 2000. We exchange data across many organizations through the use of the CCR standard (connecting with Google Health), as well as HL7 (laboratory values) for our transactions. The AIDS clinic at SFGH is an FQHC and so we are eligible for these federal HIT funds. We would use the funds to replace old and outdated servers, provide additional programming innovations, create new jobs and help with patient education and training. We would hire new software programmers for some cutting edge applications (first up is a program to help victims of intimate partner violence) and new educators to help our patients get on line and work with the team to stay connected out in the community. Thus we believe that the ARRA funds identified for FQHC and HIT should support local solutions that use open standards. We would thrive in this scenario and continue to innovate solutions for our patients and support effectiveness-based research.
The problem? So, far the government has indicated that our very fine EHR system, built on open standards, and not "CCHIT certified," may not qualify as an application for our clinic to receive new funding under the ARRA. Despite the fact that we can show (and have shown) "meaningful use" of health IT specified in the HITECH Act right with our current EHR system, and despite the fact that I have made repeated requests for clarity on who can apply for funding, and for a reasonable explanation of the meaning of "certified EHR technology," we are being told by federal officials that we may be left out of the funding opportunities. Are we faced with the alternative to scrap our current EHR system that works and replace it with one from the few EHR vendors who are "CCHIT certified" but may not work in our environment?
This makes no sense whatsover. It is critical to get the health IT spending right for the FQHC clinics, for the providers and for this population. These clinics provide the care for our most vulnerable populations. These patients are often marginalized without access to many of the needed HIT products available from commercial vendors. Many clinics, like ours, have opted to design their own systems, based upon existing open standards, to make sure that the patient population receives the advantages associated with HIT, such as health data exchange, care coordination, ePrescribing, and clinical decision support. Many others would like to adopt health IT, but may not need or want all of the many features and functions that are currently required for CCHIT certification. Also of concern is that with the new ARRA support, vendors will target this group. That is not a bad thing necessarily: however these products often are like fitting a round peg in a square hole. These companies do not always appreciate the needs of these patients and the specialty care that might be associated with their care. Although the products may have some initial attractiveness, they may carry long-term and under- appreciated costs for their continued use. Finally, if these FQHCs have special needs or tweeks that are necessary….get in the line…a response that is heard by many and unfortunately often fails to deliver new content or features.
Among the first actions CMS will need to take is to decide what constitutes “allowable costs” for this initiative to fund FQHCs. In examining this issue I am one voice among a growing chorus that propose that one-size-fits all approach like that of CCHIT will not serve us well. CCHIT is an organization that provides verification of users who have paid for the right to be self-identified as certified. This process is flawed and is not useful for specialty care or for innovative care. CCHIT does promote standards for activity and suggested functionality but one size rarely works for all situations. Certification is not consistent with innovation rather, innovation is consistent with grass root development approaches that work because they are designed by groups focused with local solutions to providing HIT for local care.
Some points to consider:
- HRSA funds for FQCH for health IT infrastructure must lead to new jobs—this will often emerge from new application development and stems from new work not simply implementation of off the shelf solutions. Existing HIT would benefit from the innovative improvements afforded by HIT and tailored for the local patient care needs.
- FQHCs are often on the “other side of the digital divide”. Solutions have developed that fit and could be shared at low or no cost to providers and organizations. Often the local solution has quality control, quality improvement and other research aspects built in already so that effectiveness research can be initiated and completed. CCHIT tools are not necessarily built to support effectiveness research.
- The CCHIT handbook states that “Our criteria at this point can only represent broad, basic capabilities, and …these may prove insufficient for some practice specialties, or may be inappropriate or excessive for others; . . . our criteria do not assess product usability, implementation service, product maintenance, technical and application support; and other facts.” In some respects CCHIT would not fit more customized and specialized uses, like at the AIDS Clinic in San Francisco. Here we have a more complete and useful solution for health IT than ones provided by more expensive vendors who are CCHIT certified. We need the support for improving our hardware (servers) and applying for this support (without license fees) throughout the department of public health.
- A better way to think of certification for HIT would be as a graded certification model—like consumer reports. There is not an approval or disapproval but a way to rate various solutions so the consumer could make an informed choice regarding the products and the best fits with their requirements—especially when cost considerations are appropriate. The CCHIT certified product comes at a cost for the end consumer (hospitals, private practices) since greater functionality equals a more expensive product.
- CCHIT certification SHOULD NOT be a requirement but a goal for applications. These support funds could be used to help local solutions build functions that are required to achieve CCHIT within some time period if this is the only game in town. But above all these ARRA funds designated to support FQHCs for health IT infrastructure should support nimble and create responses rather than fund requirements that are not clearly useful for all applications.
So what are my recommendations?
- Do not limit ARRA funds to CCHIT certified applications.
- Bring all software applications together that will facilitate effectiveness research.
- Ensure that FQHCs make the decision and choice of applications that fits their needs and not mandate the applications for the FQHCs.
My work is supported by the NIH-National Center for Research Resources (K24 RR024369), Agency for Healthcare Research and Quality (R18HSO17784) and the Commonwealth Fund . I want to thank Dr. David Kibbe for reviewing this work and his many suggestions.
JAMES KAHN MD is Professor of Medicine, AIDS Program San Francisco General Hospital and the University of California San Francisco.