Despite many physicians and hospitals now meaningfully using electronic health records, there's still a huge gap when it comes to these providers exchanging patient data. That reality has some regional extension centers taking up the work of health information exchange.

The funding, however, is often hard to come by. 

Consider New Hampshire, for instance, where the nonprofit beyond the REC is operating the HIE, and trying to meet the information technology needs of the providers as they evolve. 

  "All of us always knew the money would end. We'll definitely see some REC programs go away," said Jeff Loughlin, executive director of the New Hampshire REC and the NH Health Information Organization. But in New Hampshire, though the funding is gone, "the need is still there, and in some cases the need is here more than it ever was before." 

When the REC started out, many of New Hampshire's largest providers were already well-wired with high levels of EHRs and e-prescribing, but smaller practices needed help with adoption and complying with meaningful use – and many are now looking for help on the technology side of quality improvement projects and alternative payment models, Loughlin added.  

  To get to a point where the REC and HIE organizations can be self-sustaining and able to exist to troubleshoot problems for providers as they arise, "we remained pretty light and nimble, rather than building a big bureaucracy behind the organization," Loughlin said. "There were a number of practices we helped directly and we also engaged a number of organizations that had competent IT teams and quality improvement organizations within their walls." 

In some cases that meant offering general oversight, high-level education and tools that providers could use to achieve meaningful use. 

Although about 90 percent of New Hampshire's providers are using EHRs, "the use of that EHR and the amounts of structured data elements that are accurately being recorded is still a little bit disparate across the state," Loughlin said. 

Bridging that gap with a statewide network is the NH HIE, which has signed up 60 organizations on multi-year contracts. "Right now for the bulk of the organizations, we're supporting the transfer of care summary exchange, the CCD, for meaningful use and using the Direct standards, but using them to support the exchange of HL7 information like laboratory and radiology results," Loughlin explained, estimating that about a third of the state's providers are connected and that another third are in the process of joining. 

Indeed, the focus of New Hampshire's HIE and REC are expanding beyond just meaningful use into the medical home initiative, alternative quality care contracts with payers and also the ACO community. 

"All of those initiatives are predicated on the fact that they've got to have concrete data elements and ways to measure what's actually happening," Loughlin said. 

Loughlin is also a project director with Massachusetts eHealth Collaborative, which the state of New Hampshire hired to help write its strategic and operational plan for health information exchange in 2010, and the NH HIE is in the midst of second a long-term visioning process.