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The American Journal of Managed Care March 2013
Rates of Guideline Adherence Among US Community Oncologists Treating NSCLC
Zhaohui Wang, MD, PhD; Inga Aksamit, RN, MBA; Lisa Tuscher, BA; and Kim Bergstrom, PharmD
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Ledia M. Tabor, MPH; Phyllis Torda, MA; Sarah S. Thomas, MS; and Jennifer L. Zutz, MHSA
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Salma Shariff-Marco, PhD, MPH; Nancy Breen, PhD; David G. Stinchcomb, MS, MA; and Carrie N. Klabunde, PhD
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Engaging Providers in Underserved Areas to Adopt Electronic Health Records
Cleo A. Samuel, BS; Jennifer King, PhD; Fadesola Adetosoye, MS; Leila Samy, MPH; and Michael F. Furukawa, PhD
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Hillary R. Bogner, MD, MSCE; Heather F. de Vries, MSPH; Alison J. O'Donnell, BA; and Knashawn H. Morales, ScD
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Shlomo Vinker, MD; Eli Krantman, MD; Michal Shani, MD; and Sasson Nakar, MD
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Engaging Providers in Underserved Areas to Adopt Electronic Health Records

Cleo A. Samuel, BS; Jennifer King, PhD; Fadesola Adetosoye, MS; Leila Samy, MPH; and Michael F. Furukawa, PhD
We assessed Regional Extension Centers' (RECs') progress in promoting EHR adoption among providers in rural and health professional shortage areas and found that RECs are achieving much success in enrolling these providers.
Objectives: To assess Regional Extension Centers’ (RECs’) health IT outreach and provider engagement efforts among primary care providers (PCPs) based in underserved areas.

Study Design: A retrospective assessment of REC program enrollment.

Methods: We computed REC program enrollment rates among PCPs for the entire United States and across census regions and compared enrollment in underserved areas relative to non-underserved areas. Measures of area-level underserved status included rural and health professional shortage area (HPSA) designations.

Results: Of the estimated 302,689 ambulatory PCPs practicing in the United States, 120,783 (39.9%) were enrolled in an REC. REC enrollment rates among PCPs were higher in large rural (47.3%) and small rural (56.1%) areas relative to urban (37.9%) areas. REC enrollment rates among PCPs were also higher for single-county HPSAs (51.9%) relative to non-HPSAs (40.0%), geographic HPSAs (41.7%), and population group HPSAs (38.6%). The Northeast region exhibited the highest REC enrollment rates overall and across categories of underserved status relative to all other census regions.

Conclusions: The REC program serves as a unique opportunity to address the health information technology needs of PCPs working in underserved areas. Over the course of 2 years, the program has exceeded its goal of enrolling 100,000 priority primary care providers. Provider engagement is the first step in a 3-step process aimed at getting providers to adopt and become meaningful users of electronic health records. Significant work remains for the RECs to meet these objectives, and future research should evaluate the success of the REC program in meeting subsequent milestones.

Am J Manag Care. 2013;19(3):229-234
  • The Regional Extension Center (REC) program is assisting primary care providers in small practices located in underserved areas with adoption and meaningful use of electronic health records (EHRs).

  • RECs have exceeded their goal of enrolling 100,000 primary care providers in programs to receive subsidized technical assistance services in exchange for the provider’s commitment to work toward meaningful use of EHRs.

  • Provider engagement is the first step in a 3-step approach to assist providers in achieving meaningful use of EHRs. More work remains to assess whether RECs meet their objectives of assisting providers with implementing EHRs and achieving meaningful use.
Despite the potential of electronic health records (EHRs) to improve healthcare quality and efficiency, US healthcare providers historically have been slow to adopt them. In 2009, about 1 in 5 physicians used a basic EHR, and EHR adoption rates lagged even further among physicians in small practices with fewer than 10 physicians, physicians in rural areas, and other providers who disproportionately care for the underserved.1-5

To spur more widespread adoption of EHRs, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act as part of the American Recovery and Reinvestment Act of 2009.6 HITECH included provisions to help ensure that the benefits of increased EHR adoption would accrue equally to all types of healthcare providers and patients. One such provision directed the Office of the National Coordinator for Health Information Technology (ONC) to establish the Regional Extension Center (REC) program to provide community-based education and technical support to healthcare providers as they implement EHRs.7 Using an on-the-ground outreach approach, RECs were designed to encourage provider “buy-in” and support providers in the EHR product selection and practice integration process.8,9 In total, $677 million was allocated to establish and support RECs across the country over 4 years. Today, the REC program consists of 62 heterogeneous, non-profit organizations that have been working to promote equitable patterns of EHR adoption across the entire US geography since 2010.

While RECs are permitted to offer services to all types of healthcare providers, HITECH states that RECs “shall prioritize any direct assistance to a select group of providers” who may otherwise lack the resources to adopt and meaningfully use EHRs.6 This targeted group of providers consists of primary care providers working in: small group practices of 10 or fewer professionals; public hospitals; Critical Access Hospitals; community health centers; rural health clinics; and other settings that predominantly serve uninsured, underinsured, and medically underserved populations. The priority designation is intended to encourage RECs to support providers treating higher proportions of underserved patients and practices based in medically underserved areas who serve a vital safety-net role. Upon establishing the REC program in 2010, ONC set forth a goal to assist at least 100,000 priority primary care providers with the adoption and meaningful use of EHRs.

The RECs operate under a performance-based reimbursement structure designed to achieve 3 key Milestones with providers in their catchment areas. The Milestones are: (1) engagement and enrollment with the REC, (2) adoption of an EHR, and (3) meaningful use of an EHR (as defined by the Stage 1 Meaningful Use criteria in the Medicare and Medicaid EHR Incentive Programs).

To achieve Milestone 1, providers must make a commitment to adopt and meaningfully use an EHR system with the support of their local REC. RECs must obtain signed technical assistance participation agreements from each provider to be reimbursed for Milestone 1 achievement. The participation agreement is a contract that specifies the terms and fees required (if any) to receive specified REC services associated with each Milestone. Qualified providers must commit staff time and resources to work toward meaningful use of EHRs in exchange for receiving subsidized services. Provider engagement services associated with Milestone 1 include education and outreach on EHR options and federal incentive programs as well as planning and needs assessments. These provider engagement services assist providers with the early stages of the technology adoption decision process by increasing knowledge of EHR benefits and networking with opinion leaders who have already adopted EHRs.10

Since early 2010, the REC program has been working to promote equitable patterns of adoption and meaningful use of EHRs throughout the United States. Evaluating whether the REC program successfully helps providers achieve the 3 program Milestones will provide insight into the value of the program investments and how the REC model may be useful in supporting future delivery system modernization efforts. The REC program is the subject of an ongoing national evaluation that will provide summative feedback across all 3 Milestones when the HITECH funding period concludes. However, monitoring progress on an interim basis is also important.

Now is an opportune time to examine the progress of RECs toward Milestone 1. In the early phases of the program, RECs focused on engaging and enrolling providers before shifting their focus to assisting those providers through the next Milestones of EHR implementation and meaningful use. However, the progress of RECs toward their goal of engaging 100,000 providers, especially penetration in underserved areas, has not been systematically documented to date. This analysis examined REC enrollment (Milestone 1) among primary care providers (PCPs) with a focus on 2 types of priority settings: rural areas and health professional shortage areas. In addition, the analysis sought to highlight geographic variations in provider engagement, to identify existing gaps, and to offer recommendations for promoting increased provider engagement in underserved areas.


Data Sources

Data on PCPs enrolled with an REC came from the REC program’s proprietary customer relationship management (CRM) database. As part of their funding agreement, RECs are required to report data into the CRM on individual provider credentials, provider specialty, Milestone achievements, and the practice location (address) at which the Milestone is achieved. If an individual provider practices in more than 1 location, the REC must select 1 location for the Milestone achievement (ie, RECs can receive credit for achieving Milestone 1 once per provider; RECs cannot receive additional credit for enrolling the same provider in multiple locations). Data collection began in January 2010 and data are collected on a rolling basis.

Data on the total number of PCPs in each REC’s geographic catchment area were obtained from the 2011 SK&A Office-based Providers Database, a product of SK&A Information Services, Irvine, California. The database is designed to comprise a census of all providers in an ambulatory healthcare site with at least 1 provider with prescribing authority in the 50 states and the District of Columbia. The database includes information on each provider including practice location, provider credentials, and provider specialty. Data are collected and verified through a rolling telephone survey (all sites are contacted twice a year).


REC-Enrolled PCPs. As of February 2012, a total of 134,463 providers were enrolled with an REC (Milestone 1). To ensure comparability with SK&A, we limited our analyses to REC-enrolled physicians, physician assistants, and nurse practitioners with specialties of Family Practice, General Practice, Internal Medicine, Geriatrics, Obstetrics and Gynecology, Pediatrics, and Adolescent Medicine. We excluded providers located in the US territories (ie, American Samoa, Guam, Northern Mariana Islands, Marshall Islands, Palau, Puerto Rico, and US Virgin Islands). The final data set included 120,783 PCPs, which comprised 89.8% of all providers enrolled with an REC.

Total Number of PCPs. To ensure comparability with REC data, we limited the SK&A data to physicians, physician assistants, and nurse practitioners located in the 50 states and DC with the primary care specialties listed above. In 2011, there were 302,689 such PCPs in the SK&A database.

Rural and Health Professional Shortage Area Designation. We explored REC penetration across 2 types of areas: rural areas and health professional shortage areas (HPSAs). County-level rural status was based on the Core Based Statistical Area (CBSA) designations obtained from the 2010 Area Resource File. Under this designation, counties belong to 1 of 3 categories: metropolitan (urban); micropolitan (large rural); and non-CBSA (small rural). Among these categories, non-CBSA indicates the greatest degree of rurality.

County-level HPSA designations were derived from the Health Resources and Services Administration’s (HRSA’s) November 2011 Primary Care HPSA data file. We characterized counties in 4 categories: non-HPSA (no shortage); geographic area HPSA (shortages in specific geographic areas within the county but not the entire county); population group HPSA (shortages for specific population groups that may be present in a specific geographic area within the county or across the entire county); and single-county HPSA (shortages spanning entire county area and population). Among these categories, single-county HPSA indicates the greatest degree of health professional shortage for a given area.


We calculated REC enrollment rates among PCPs using a numerator of REC-enrolled PCPs and a denominator of total PCPs. We calculated enrollment rates for the nation overall, for each of the 4 Census regions (Northeast, Midwest, South, and West), and by county. We then calculated enrollment rates within each category of underserved area designation at the national and regional levels. Finally, we mapped enrollment rates for each county in the nation to visually assess geographic variation in enrollment rates.

Of the denominator of 302,689 PCPs, 14% (n = 43,453) were observed in multiple practice sites; 9% (n = 27,729) were in multiple sites in the same county; and 5% (n = 15,724) were in sites in more than 1 county. When calculating enrollment rates by county and underserved area designation, we divided these PCPs evenly across their practice locations. For example, if a PCP was observed in 2 practice locations each in a different county, we counted the PCP as 0.5 providers in each county.

A small number of counties (n = 7) reported positive REC enrollment (eg, 1-5 PCPs) but zero PCPs in the SK&A data. We included these enrollment numbers in the nationwide and region estimates of county-level enrollment rates.


Of the total office-based PCPs in the United States, 120,783 (39.9%) were participating in an REC as of February 2012 (Table). However, we found variation in overall enrollment rates across Census regions, ranging from 34.7% in the South region to 45.7% in the Northeast region. This geographic variation was evident when visually examining county-level REC enrollment rates as well (Figure).

REC enrollment rates were highest in the most rural areas. Relative to metropolitan areas, REC enrollment rates were higher for small rural (non-CBSA, 56.1%) and micropolitan areas (47.3%). This pattern was present in the nation overall and within all Census regions.

REC enrollment rates were also highest in counties with the highest degree of health professional shortages. We found that REC participation was highest for single-county HPSAs (51.9%) relative to non-HPSAs (40.0%), geographic HPSAs (41.7%), and population-group HPSAs (38.6%). In all regions, REC enrollment rates were highest in single-county HPSAs.

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