Widespread use of interoperable electronic health records is necessary for transforming how health care is delivered and will be a key enabler of health care reform.
The Health IT provisions of the American Recovery and Reinvestment Act seek to promote nearly universal EHR adoption over the next 10 years, largely through incentive payments to be paid following meaningful use of EHRs for improvements in health quality, efficiency, prevention and safety.
However, successful implementation of EHRs is challenging, especially among small practices where most primary care is delivered.
These practices generally lack expertise and resources to purchase, install and use information technology to work better and more efficiently. Furthermore, despite the requirements for standards and certification, uncoordinated EHR implementations are unlikely to result in functional interoperability between systems.
In order to achieve the goal of meaningful EHR deployment, it is essential that the final recovery package supports funding for implementation through regional extension centers across the country.
Local Support Needed
Obtaining real value from these unprecedented federal investments will require local support organizations that help doctors install these systems and use them to achieve improved quality, efficiency, and continuity of care.
The Massachusetts eHealth Collaborative and the New York City Primary Care Information Project are two examples of community projects that have successfully supported the implementation and meaningful use of EHRs, through direct purchase and provision of software and services, and local "boots on the ground."
The act does provide for the creation of "Regional Health IT Extension Centers" that -- if empowered appropriately -- could be structured to meet this need. Such centers must be:
Funding of EHR extension through community extension projects could create a clear point of accountability in each region.
Clear metrics can monitor their progress in implementing systems, achieving meaningful use, and obtaining clinical and administrative improvements.
In addition, relying on community extension projects would let states distribute the administrative burdens of monitoring practice-level compliance and meaningful use.
The HIT Extension Program also could evaluate different community-based approaches and share lessons between the regional centers. Unlike individual practices, community projects can retain a clear focus on attaining public benefits beyond the technology itself -- that is, improved public health, quality of care, health system efficiency and equity and continuity of care.
PCIP has achieved a greater than 99% successful implementation rate among practices in underserved communities.
Community projects must bring expertise and rigor to EHR selection, and effectively act as intermediaries between vendors and practice by: preparing practices for and managing implementation; troubleshooting problems; and assuring cooperation with third parties (such as laboratories, pharmacies, health plans) when needed.
These end-to-end structures generally cannot be managed by individual private practices and are the key components that provide longer-term value to the practices, their patients and the health of the community.
Community projects can work more effectively with EHR vendors to improve their products and services and to harmonize the range of practice requests at a community level.
MAeHC assured interoperability and information exchange between practices using different EHRs.
PCIP drove development of novel EHR supports for better population care (registry functions, automated quality measurement, and prevention reminders).
The security of patient information is a key concern of both patients and providers. Assuring that security not only requires features built into technologies, but also policies and practices.
Community projects must work with practices to educate, train and assure that steps aimed at ensuring security are taken, including physical security, password and access policies, protected and encrypted data backups, and protection against social hacking.
Establishing a uniform and robust "floor" on security requirements is one of the most important functions that community projects provide.
Health information exchange is crucial for care coordination and patient safety and will not occur through standards and certification alone.
Community projects must ensure that systems are implemented in ways that support data interoperability and enable participation in regional information exchanges where they exist.
Furthermore, community projects can allow providers to compare their performance on quality measures to their peers, and to share best practices on how to achieve better outcomes.
Community projects can generate economies of scale that will allow federal dollars to go further.
By pooling implementation experts and building a strong base of knowledge and expertise, community projects provide implementation services to physicians at a much lower cost than the physicians could purchase on their own. They must use their size and scale to obtain substantial discounts on hardware, software and services, which would not be available to individual practices.
Community projects also can seek additional support from state and local governments and foundations that extend the impact of the federal investment.
Ingredients for Success
In order to meet these expectations, community projects must:
- Be sponsored by one or more locally trusted organizations with proven operational capabilities (e.g., government entities, independent physician associations or local health systems);
- Have flexibility to act as group purchasers of software, hardware and services for their communities;
- Receive significant upfront funding to support initial adoption and meaningful use of EHRs among willing practices; and
- Have delegated authority from states and the HHS secretary to evaluate and certify "meaningful use" of EHRs as defined by federal standards.
Community projects ensure that the implementation of electronic health records is focused on public benefits that might otherwise get overlooked.
We fear that a historic opportunity to achieve quality and efficiency gains through health IT expansion will be lost unless federal strategy is grounded in the proven success of the community extension model.
Editor's Note: This statement bears the signatures of more than 50 leaders in health care from 26 states who advocate health IT use in their clinics, hospitals, health systems and communities. National organizations such as the National Committee for Quality Assurance, the National Partnership for Women & Families, the eHealth Initiative and the Pacific Business Group on Health also endorsed the statement.
 Blumenthal D, The Federal Role in Promoting Health Information Technology, The Commonwealth Fund, January 2009
 Mostashari F, Tripathi M, Kendall M. Lessons Learned From Two Large Community Electronic Health Record (EHR) Extension Projects. Health Affairs 28(2). March 2009 Forthcoming