PROVIDENCE – By June of 2005, efforts to launch the new enterprise, EHR of Rhode Island, had picked up steam, according to minutes of the board meeting of the R.I. Quality Institute held on June 1, 2005.

The core group, Dr. Mark Jacobs of Coastal Medical, Dr. Andrew Snyder from Lifespan, Maria Montanaro of Thundermist, and Laura Adams of the R.I. Quality Institute, were readying for a launch by the end of summer/early fall.

To do that, the group was moving quickly to get the buy-in and secure financial backing of some of the biggest health care companies in Rhode Island – including Lifespan, Blue Cross & Blue Shield of Rhode Island, Care New England and UnitedHealthcare.

Plans had been developed for activities to be undertaken, described in business-plan terms: “concept shopping, business planning, organizational development, capitalization and product exploration.” [interoperability appeared to have been dropped from the criteria.]

Jacobs reported on his recent meeting with George Vecchione, president and CEO of Lifespan, who, according to Jacobs, pledged resources to help in the early phase of development and business planning. Jacobs said he had also met with RISE, Lifespan’s medical malpractice carrier, and reported that they were “very supportive of the concept.”

Contact had also been made with NorCal, another malpractice insurance carrier, in preparation for a meeting to seek financial support.

Jacobs also reported that he had “a great meeting” with Jim Purcell, the president and CEO of Blue Cross & Blue Shield of Rhode Island, who was strongly supportive of the EHRRI concept. Purcell, like Vecchione, pledged his support and offered resources for the early phase of development and business planning.

[Purcell’s pledge of financial support would become $300,000 initial funding, which would eventually balloon to $1 million.]

Jacobs said that he would extend the same “invitation” to UnitedHealthcare.

Jacobs said that he and the other three core group members had also met with Christopher F. Koller, the R.I. Health Insurance Commissioner, who Jacobs said was very supportive. Koller spent a considerable amount of time brainstorming strategies for workable models and a successful launch.

Contracting out the business plan
The separation between the Clinical IT Leadership Committee and the core group planning EHR of Rhode Island became more pronounced, as the new enterprise enters into discussions that lead to a consulting contract with MedPharm Partners for business planning, a firm recommended by Micky Tripathi, the CEO of the Massachusetts eHealth Initiative, according the minutes of the R.I. Quality Institute board meeting held on July 13, 2005.

The “founders of EHRRI,” as the core group is now referred to in the minutes, met with David Williams and Rick Lifsitz of MedPharma on June 20, to discuss retaining that firm to write the business plan and business case for EHRRI. A revised consulting contract with MedPharma was expected to be finalized very shortly, according to Jacobs.

A meeting was held on July 8 with representatives of NorCal, including Stephen Farber and Todd Manglass, to discuss the most appropriate vehicle for the medical malpractice insurer to support the EHRRI initiative, according to Jacobs. While premium reductions or premium rebates would be difficult because of state filing issues, NorCal was interested in exploring the possibility of participating through grant funding to support EHRRI.

Quality vs. cost
As the evaluations begin to determine which vendor to select to be part of the EHRRI initiative, the choices narrowed to three potential vendors: NextGen, Practice Partners and eClinicalWorks, according to the minutes of the Clinical IT Leadership Committee held on Aug. 4, 2005.

It is at this juncture in the decision to choose a vendor where the EHRRI initiative appeared to veer off the rails, favoring the lower cost of one system, eClinicalWorks, above the higher quality of another system, NextGen.

Dr. Andrew Snyder began the discussion by saying that all three products were very high quality, and could not be differentiated by function. Instead, he argued, there was a need to look at the ease of use, the ease of reporting, the flexibility, the cost, and the future corporate stability.

NextGen was identified as the “gold standard”: it was deemed the most robust, with an excellent practice management system, was relatively flexible, and that it was stable as a corporation. The drawbacks were that it had the steepest learning curve, and was “the most costly of the products under consideration.”

Another potential drawback was concern voiced about how easy it would be to customize NextGen templates. Another worry, according to Snyder, was that, given the popularity of NextGen, with a high number of “implementations” now in progress, would there be a capacity issue in the near-term.

In looking at Practice Partners, Snyder said that the system is much more user-friendly, intuitive, and easier to template, compared to NextGen – although template changes still had to be done by the vendor. Snyder characterized Practice Partners as being medium in price-range. Snyder reported that the principals of the company, based in Seattle, had stayed in constant contact with EHRRI and had expressed a strong desire to be selected as the vendor of choice, including offering to put an office in Rhode Island and helping to develop innovative financing strategies.

The drawbacks with Practice Partners were identified as a less well-developed practice management system; Coastal Medical had examined the Practice Partners’ system in depth and said that the practice management component was a step back from Medical Manager [another EHR product].

Maria Montanaro of Thundermist raised questions about Practice Partners, saying that it was being used in only two community health centers out of some 1,400, and neither of those centers were as large and sophisticated as Thundermist. In her opinion, Practice Partners was “about a decade behind NextGen” in meeting the specific needs of health centers, according to the minutes.

Dr. Peter Ceriani raised a question about what should be given priority in the review of vendors: the clinical capabilities of the EHR or the practice management system. Snyder answered that while both were important, if a compromise were required, it would occur more on the practice management side rather than compromise the clinical capability.

Snyder then reported on the review of eClinicalWorks. In the first “cursory” review of the product, concern was voiced that the technology would not scale up and the reporting functions were not as robust as the other products. But, taking into account Aquidneck Medical Associate’s more in-depth review, eClinicalWorks had been found to be very scalable, extremely flexible, intuitive and easy to use, according to Snyder.

Dr. David Gorelick of Aquidneck Medical Associates explained that Aquidneck Medical Associates had decided to go with eClinicalWorks, even if EHRRI were to choose another vendor. Gorelick expressed a high degree of satisfaction with how the EHR software product was meeting the physician group's needs.

Montanaro said that were some issues with eClinicalWorks regarding their reporting capability, including an inability to adjudicate a sliding scale fee.

Snyder said that eClinicalWorks had about 1,400 installations at present. Further, he said that eClinicalWorks were highly motivated to work with Rhode Island and had offered some strategies for long-term partnerships, such as a joint venture with EHRRI.

The cost of eClinical Works was substantially less than NextGen and lower than Practice Partners, as well.

Financial support for EHRRI’s business planning effort from Rhode Island’s two largest hospital systems and two largest commercial health insurers was announced.

Laura Adams, one of the founders of EHRRI, announced that a contract for the first phase of the enterprise’s business plan was about to be signed. The contract, she said, was being funded by Care New England, Blue Cross & Blue Shield of Rhode Island, Lifespan and UnitedHealthcare. [The actual amount of the contract was not included in the minutes.]

The money for the contract was being funneled through the R.I. Quality Institute “as a neutral third party” in relationship to EHRRI founders. [Issues related to potential conflict-of-interest in Adams’ role in both organizations would surface later.]

Articles of Incorporation
In eight short months since the concept of a new entity to manage the group purchasing of EHR software for Rhode Island physicians had been proposed, the name of the new entity, EHRRI, had been secured with the R.I. Secretary of State, and final drafts of the incorporation papers and operating agreements were being prepared, according to the minutes of the Rhode Island Quality Institute board meeting held on Sept. 9, 2005.

Work continued to “capitalize” the new company, EHRRI. Dr. Cedric Priebe of Care New England, Dr. Mark Jacobs of Coastal Medical, Dr. Andy Snyder of Lifespan, and Laura Adams of the R.I. Quality Institute met on Sept. 1 with Stephen Farrell and Neal Galinko of UnitedHealthcare.

The minutes report that a “lengthy and productive meeting” was held with Girish Kumar of eClinicalWorks, a finalist to become the joint venture partner with EHRRI.

The Westborough, Mass.-based company, founded in 1996, has no venture capital involvement and is not leveraged in any way, according to the minutes. The company’s revenue stream does not depend upon selling upfront licenses, but works from a subscription services model, setting up recurring income in the future.

Jacobs said that eClinicalWorks “shared the vision” of EHRRI, which is “tightly aligned” with that of the R.I. Quality Institute. That vision includes lowering the barriers to enable solo and small practices to adopt a highly functional EHR system. Further, eClinicalWorks offered to provide strategic and business process input to EHRRI, and to sit on the EHRRI board, if asked. 

Adams said that work had begun to align the EHRRI business plan with the R.I. AHRQ Health Information Technology project [Currentcare].

Finally, Adams said eClinical Works, as part of the joint venture with EHRRI, had agreed to provide their product and services to the R.I. Free Clinic.

The honeymoon phase
The minutes from the Clinical IT Leadership Committee held on Sept. 15, 2005, reveal the founding members of EHRRI to be excited about the potential “unique” relationship with eClinicalWorks as the chosen vendor.

The plan, according to Snyder, is to craft a long-term partnership in the form of a joint venture, rather than a vendor-client relationship.

Adams framed the context by saying that “what Rhode Island physicians need from the product will evolve over time,” and EHRRI can partner with eClinicalWorks to co-create new features and functions of the system.

A series product demonstrations were scheduled at Thundermist, Women and Infants and Lifespan for physicians, beginning the week of Sept. 22. Another product demo was scheduled in October at Kent Hospital.

It was reported that eClinicalWorks was selected as one of the vendors by the Massachusetts eHealth Collaborative, and that product sales were reported to be “very brisk” in communities that were given funds to purchase the company’s EHR software product.

On the business front, Snyder reported that work was going more rapidly than expected, with the first phase of the business planning process completed and efforts to incorporate EHRRI well underway. Accountants have also been engaged.

Gorelick reported on Aquidneck Medical Associate’s experience in implementing the eClinical Works product as its EHR software. He reported that the time commitment to training and learning the system was more than anticipated. He recommended that identifying a physician champion, a nurse champion and a practice management champion were critical to the success of the implementation.

Much of the discussion then focused on developing a pay for performance system of incentives, led by Dr. Nitin Damle, the co-chair of the R.I. Quality Institute Incentives and Sustainability Committee. The conversation honed in on the role that the Clinical IT Leadership Committee might play in shaping the design of the pay for performance incentives that support IT adoption and use to improve health care quality, safety and value.

Dr. Gus Mannochia of Blue Cross & Blue Shield of Rhode Island pointed out that the insurer had begun reimbursing for counseling for end-of-life care and advance directives, beginning Jan. 1, 2005. As long as the services are provided face-to-face at a time when the patient is present for some or all of the discussion, he continued, it was appropriate to bill for evaluation and management codes. “This is true for services in all settings,” he said, according to the minutes.

A logo and a website
Dr. Mark Jacobs was named the first board chair of EHRRI, it was announced by Lifespan’s George Vecchione at the Rhode Island Quality Institute board meeting held on Oct. 5, 2005, according to the minutes.

A new logo was also unveiled, designed by Lifespan’s Dr. Andy Snyder. A new website was also announced [Today, that link appears to be defunct, and instead connects to what appears to be a website in Chinese]. Ads placed in the Providence Journal and the Boston Globe to recruit a CEO for EHRRI were shared with the board.

The incorporation papers were expected to be signed later that week, according to the minutes.

In the Clinical IT Leadership Committee update, it was reported that Chris Koller, Dr. Nitin Damle and Laura Adams met on Oct. 3. Koller said that in addition to developing a plan for sustainability, interoperability and clinical data sharing, there was work to be done in Rhode Island in creating and sustaining changes in practice and care delivery. “Sustainability models developed to support the latter will likely include changes in the flow of money,” Koller said, according to the minutes, presaging the work done on the R.I. Chronic Care Sustainability Initiative. [CSI-RI, now the CTC.]

The marketing campaign begins
In the first report by EHRRI to the board of the R.I. Quality Institute, dated Jan. 4, 2006, it said that Blue Cross & Blue Shield of Rhode Island had made a $300,000 contribution to the new company to fund the start-up costs of EHRRI.

It was also reported that eClinicalWorks had agreed to contract terms, a marketing letter had been sent to physicians in Rhode Island, and EHRRI had been written about in an article in the Dec. 20, 2005, issue of Modern Healthcare.

The tasks ahead included: the need to raise $2.5 million to offer a minimum 15 percent discount on the eClinical Works product to Rhode Island physicians. Raising $5 million would allow a 30 percent discount.

Pushback on selection of eClinicalWorks
In the Rhode Island Quality Institute minutes from the board meeting held on Jan. 4, 2006, the first sign of buyer’s remorse appeared from Dr. Al Puerini, the developer of a competitive EHR product, EpiChart.

Puerini, in his capacity as president of the Rhode Island Primary Physician’s Corporation, or RIPCPC, expressed concern that the Rhode Island Quality Institute and its Clinical IT Leadership Committee was creating the impression that there would be only a single system selected by EHRRI that would meet the state criteria for interconnectivity. The letter noted that Puerini and Chris Dacey, the executive director of RIPCPC, were members of the Clinical IT Leadership Committee for the past two years.

In the discussion that followed, Dr. Yul Ejnes of the Rhode Island Medical Society said that a subset of the RIPCPC physicians had invested in a for-profit company, Polaris, which had developed the EHR product called EpiChart.

Ejnes said that Coastal Medical had gone through a lengthy process to select a software product, but had not chosen EpiChart; instead, it had chosen NextGen.

But, when EHRRI decided to choose eClinical Works, Coastal Medical had reversed its decision and, based on Dr. Mark Jacobs recommendation [Jacobs was a founding member of EHRRI], the group practice chose to go with eClinicalWorks, not the software product that had been recommended through Coastal Medical’s in-depth comparison of products.

Ejnes said that he had to do a “significant amount of introspection” but finally came to accept Jacob’s recommendation to go with eClinicalWorks, based upon Jacob’s position that it would be best for the state and “enable Rhode Island to move closer to the vision of statewide adoption of EHRs.”

Jim Purcell of Blue Cross & Blue Shield of Rhode Island said that from the insurer’s perspective, most of their funding for EHRs in Rhode Island would be funneled through EHRRI, because of the statewide nature and potential reach of the new entity. However, he continued, Blue Cross did have agreements in place with RIPCPC that promote the adoption and use of EHRs.

Jacobs said that the intent of EHRRI was not to “limit choice” but to provide a highly functional option in the marketplace, lower the cost of this type of option, promote the widespread adoption of EHRs, and decrease the number of interfaces that would need to be written to different EHR systems.

Vecchione offered a clarification, saying that the Rhode Island Quality Institute’s relationship was “never to support a single vendor,” but instead to support “this demonstration of extraordinary physician leadership and unprecedented collaboration.”

At the same meeting, Laura Adams reported that the Rhode Island Quality Institute had received a grant of $100,000 for 2006, with a merit-based renewal for another $100,000 in 2007, from the Rhode Island Health and Education Building Corporation, thanks to the considerable efforts of Ed Quinlan of the Hospital Association of Rhode Island.

The grant would support the involvement of consumers in health information technology to ensure that the new system has the best possible chance of being truly patient-centered.

Press conference at State House Rotunda
The official launch of the new company, EHR of Rhode Island, and the partnership with eClinicalWorks, was planned to be announced at a news conference at the State House Rotunda on April 10, 2006, according to the minutes of the Rhode Island Quality Institute board meeting held on April 5, 2006.

In an article published in The Providence Journal on April 11, it was reported that an organization called Electronic Health Records of Rhode Island reached a deal with the Westborough, Mass.-based eClinicalWorks to provide participating doctors with its software at a discounted rate. EHRRI’s goal was to wire the entire state of Rhode Island, according to the article.

Potential conflicts of interest
At the Rhode Island Quality Institute’s annual meeting on May 3, 2006, the minutes reflect that a question arose about the Institute’s relationship with EHRRI, and whether this was of concern relative to the Code of Conduct guidelines.

Attorney Linn Freedman of Nixon Peabody said that EHRRI was similar to any other entity that board members might be involved in, and that the Rhode Island Quality Institute had no legal relationship with EHRRI.

Laura Adams said that there was a possibility that about $13,500 was given to EHRRI prior to their incorporation to assist with the development of their business plan. [This apparently refers to the money from Blue Cross & Blue Shield of Rhode Island, UnitedHealthcare, Lifespan, and Care New England that was funneled through the Rhode Island Quality Institute to pay a consultant for the development of a business plan for EHRRI.]

Questions were also raised about the propriety of Adams sitting on the board of EHRRI as an at-large member but not necessarily representing the Rhode Island Quality Institute. According to the minutes, pros and cons of Adams remaining on the EHRRI board were discussed. Adams said she would take into consideration the discussion in making a decision whether to resign from the board.

[Adams allegedly stayed on the board of EHRRI for three more years, until 2009.]

Lessons learned
Five years later, by 2011, the attempt to create a statewide entity to market one software product, eClinicalWorks, had failed.

Despite strong support from the Rhode Island Quality Institute and financial backing from top leaders of the Rhode Island health care establishment, the market spoke, and different EHR products emerged.

As the minutes of the board meetings and committees of the Rhode Island Quality Institute document, an idea that began with good intentions veered off course, as the decision to choose lower cost over higher quality backfired. EHRRI closed up shop in 2011, its assets apparently transferred to the Massachusetts eHealth Collaborative, with an office set up at 1 Davol Square in Providence.

Perhaps the biggest irony is that one of the original goals of the effort was to create a system of interconnectivity and interoperability between Currentcare, the state’s health information exchange, and the EHR software product chosen by EHRRI, eClinicalWorks. However, that interconnectedness and interoperability has proven elusive at best, and costly to achieve.

There has been no apparent public report, study or analysis of what went wrong, in an attempt to understand what lessons could be learned from this failure.

However, moving forward, it would behoove the R.I. General Assembly and Gov. Gina Raimondo’s administration to begin to look at future plans for the state’s health IT infrastructure.