Monday, September 27, 2010

Regional Extension Centers and HIE

The Software Advice team has written an interesting critique on recently created Regional Extension Centers (RECs) designed to advance adoption of EHRs. You are invited to complete their online survey with special emphasis on reporting anecdotal experience with these organizations. Although it is probably too early to draw substantial conclusions, I agree with Houston Neal that RECs will remain ineffective. My arguments suggest inadequate public funding and institutional arrangements, while his deplore the slow pace of government programs and their interference with free market dynamics.

As Neal points out, the eHealth Initiative has published a disappointing report on RECs to assess progress in their implementation across the US. They have also issued their 2010 report on Health Information Exchange (HIE).

Under the Health Information Technology Research Center (HITRC), RECs were created to provide technical assistance, guidance and information on best practices to support meaningful use of Electronic Health Records (EHRs). The competitively selected RECs - announced in February and April 2010 - serve health care providers within their geographical areas. The Survey of Regional Extension Centers, Planning for Adoption: The Early Direction of Regional Extension Centers (September 2010), presents the following findings (page 3):
  • Many Regional Extension Centers remain in the planning stages.
  • Progress has been slow in transitioning pre-award letters of commitment
    by providers to signed contracts by PCPs with a Regional Extension
  • Opinion is evenly divided on progress toward REC objectives being reliant
    upon assistance from the Health Information Technology Research Center.
  • Among Regional Extension Centers planning to offer a preferred EHR
    vendor list to PCPs, the most important criteria for selecting a preferred
    EHR vendor are:
    o Price/ total cost of ownership over 3 years
    o Guarantee of meaningful use functionality
    o The number of installations locally
    o Use of an ASP hosted model
  • After stimulus funds are removed, a majority of Regional Extension
    Centers will change their fees as a means to sustainability.
The sample for this survey included only 46 of the 60 RECs in operation. The above findings suggest difficulties in defining the relationships among RECs and other health care institutions, as well as the lack of a sustainable business model. It is also not clear how these centers will provide support services across the US. The competitive selection process for RECs considered neither the issue of comprehensive geographical coverage, nor design of the requisite institutional arrangements with RHIOs, the HITRC or SDEs. I pointed out some of these weaknesses in my commentary on the proposed REC design and selection process last year.

The eHealth Initiative has also published a report based on their Seventh Annual Survey of Health Information Exchange - The State of Health Information Exchange in 2010: Connecting the Nation to Achieve Meaningful Use. The survey identified 234 active health information exchange initiatives (HIEs) in the US, among which 199 responded to and qualified for inclusion in the 2010 Annual Survey on Health Information Exchange. It should be noted that 48 of 56 state designated entities (SDEs) have been included in this sample. This shift in the definition of health information organizations needs to be taken into account in the survey findings reported. On page five, a description of the geographical coverage of organizations included in the survey shows that they cannot be considered comparable in size or clientele:

"Most non-SDE initiatives are operating at a multi-county coverage area. Fifty-five
initiatives report covering a multi-county area, while 21 initiatives report covering an
entire state. Other coverage areas include: 17 at a multi-state level, 11 at a county level,
7 at a metro level, 5 that do not cover a geographic area, and 6 initiatives that cover
another area such as part of a city or county, or are working with a specific population

While the 2010 survey claims an increase in the number of operational exchanges, the rate of "mortality" among the sample from 2009-2010 is not considered, nor is the redefinition of "exchange initiatives" (defined as RHIOs in earlier reports) to include state designated entities (SDEs). The interpretation of survey results makes no distinction between state and federal programs for health information exchange.

In 2009, 57 health information exchange initiatives reported being operational. In 2010,
the number of operational health information exchanges increased to 73, 5 of which
report being SDEs. (page 8)

At least 28 of the 2009 respondents who did not respond to the 2010 survey were thought to continue their pursuit of HIE - although there is no data presented to support this assertion. The research methodology does not clearly state the total number of organizations included in the 2009 survey who did not respond in 2010. This number is essential to evaluate the 2010 survey response rate as well as sample mortality. (In my commentary on the 2009 survey, I identified similar problems in the research methodology.)

The significant methodological deficiencies of the surveys conducted by the eHealth Initiative seriously undermine the optimistic claims made by their authors.
Some useful websites:

The State HIE Toolkit
The State Health Information Exchange Leadership Forum
HIMSS Health Information Exchange
The Office of the National Coordinator for Health Information Technology (ONC)
Wikipedia Regional Health Information Organization
Nationwide Health Information Network Overview (ONC)
Public Health Informatics Institute (PHII)

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