A Tale Of Two Large Community Electronic Health Record Extension Projects

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This is a systematic review of the article entitled “A Tale of Two Large Community Electronic Health Record Extension Projects” by Farzad Mostashari [1].


The nationwide adoption of Electronic Health Records (EHRs) is an essential constituent of federal and state health reform, however adoption rates are quite low. The Massachusetts eHealth Collaborative (MAeHC) and the New York City Primary Care Information Project (PCIP) exemplify efforts to overcome poor EHR implementation rates in community health centers (CHCs) and independent physician organizations. The MAeHC and PCIP projects were able achieve extensive adoption of EHRs across their network. This article provides insight into both of these large-scale projects, and offers viewpoints on complementary approaches and lessons learned.

The Massachusetts eHealth Collaborative


MAeHC was instituted in 2004 as a non-profit organization with a mission to “facilitate ubiquitous adoption of EHRs in the commonwealth of Massachusetts”. It originates from the three-prong leadership of the American College of Physicians, the Massachusetts Medical Society and a $50 million investment from Blue Cross Blue Shield of Massachusetts.

Community-based focus

On December 6, 2004, MAeHC initiated recruitment for three pilot programs in greater Brockton, greater Newburyport, and northern Berkshire County in order to evaluate the costs, merits, drawbacks, and barriers to widespread implementation of EHRs and Health Information Exchange (HIE).

Building an organization

In order to fulfill the great expectations of statewide EHR implementation, MAeHC created the following organizational model:

(1). Senior relationship managers: works with community leaders to provide cooperative approach to the local program

(2). Practice consultants: facilitates workflow redesign

(3). Project managers: tracks project milestones

(4). Technical managers: provides technical expertise such as design and configuration of EHR systems and interfaces

(5). Other essential functions such as database management, evaluation, communication, accounting and bookkeeping

Choosing vendors

MAeHC selected and deployed four vendors for their pilot project: Allscripts, GE Centricity, eClinicalWorks, and NextGen. In addition, the design and configuration of hardware was maintained by MAeHC technical experts and Concordant, an integration vendor.

Current Status

MAeHCs launched its first EHR system in March 2006. A year and a half later, MAeHC was able to bring 97 percent of its participants onto EHRs under the guidance of practice consultants. Post-implementation, MAeHC has focused on:

(1). Improving adoption rates of low usage providers

(2). Encouraging more physicians to use EHR functions

(3). Arranging clinical documentation across providers for improved performance evaluation

The New York Primary Care Information Project


PCIP was created in 2005 by New York City Department of Health and Mental Hygiene as an initiative to improve population health in less privileged communities through health information technology. The program has three areas of concentration:

(1). Prevention through the use of information systems

(2). Updates in care management and practice workflows

(3). Compensation for prevention and management of chronic disease

Developing and deploying a quality-focused EHR

The city of New York made it a priority to provide EHRs in all community health centers (CHCs) by the end of 2009 because only three out of twenty-nine CHCs were using EHRs. In March 2007, the city nominated eClinical Works as their choice vendor for EHRs based on its high quality and track record with MAeHC. By October 1, 2008, PCIP had attained EHR systems for over 1,400 providers.

Supporting office redesign and quality improvement activities

PCIP provided numerous implementation services such as project management, clinical workflow analysis, interface development and vendor relations. Billing and EMR consultants were also available to troubleshoot and teach best practices.

Creating a framework for a pay-for-prevention system

Establishment of integrated EHR systems enable participants in PCIP to send summaries of their quality measures to a Quality Reporting System for the city. The data obtained from these quality and performance assessments allow PCIP to provide up to $200, 000 per physician in EHR-enabled practices for good management practices such as a well-managed cardiovascular patient.

Future Plans

PCIP intends to continue to expand prevention-oriented EHRs as well as provide patients with EHR-linked personal health records.

Contrasting Approaches

MAeHC promotes continuity of care within specified communities while PCIP embraces improvements in preventative care and chronic disease management in a population.


MAeHC strived to intervene in three communities with an objective of attaining 100 percent EHR coverage while PCIPs target is to recruit 25-30 percent of high volume primary care providers serving the less privileged of New York City.

Practice contributions

MAeHC funds all direct costs of EHR implementation while PCIP only covers the cost of software and training. PCIP also requires a $4,000 cash contribution from each provider, which is placed in a quality improvement fund.

How many EHR Vendors?

MAeHC consents to providers choosing from among four vendors. PCIS only allows one vendor.

Lessons Learned: Why it is Harder Than it Looks

  • A minority of implementations sites will consume the majority of resources.
  • Creating scalable solutions such as standardization of implementation processes is challenging.
  • Establishing electronic interfaces for [health information exchange] and interoperability is difficult.
  • Widespread EHR implementation may be a prerequisite for improved public health, quality of care and health system efficiency but may not be sufficient enough to achieve this ultimate goal.


Although the initiation and completion of an EHR implementation is difficult, it is achievable. Strong leadership and millions of dollars are needed as well as knowledgeable managers and teams. Most importantly, the collaboration of vendors and communities to discover scalable solutions is vital to widespread EHR adoption.


This article is essential reading for clinicians, hospitals, vendors and stakeholders in the health industry. An overall “big picture” about the nuts and bolts of EHR implementation in two different settings is provided. This information would prove useful to any community or health entity that desires to take on the enormous task of EHR implementation.

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  1. A Tale of Two Large Community Electronic Health Record Extension Projects. [Health Affairs 28, no. 2 (2009): 345–356; 10.1377/hlthaff.28.2.345] http://content.healthaffairs.org/content/28/2/345.full.pdf+html