The written comments flowing into the Office of the National Coordinator for Health Information Technology about the proposed Regional Extension Center program demonstrate the vast array of opinions about how many extension centers should be created, who should run them, and how broad their focus should be.

In a non-scientific survey of the eHealth Initiative's members and organizations in May, 49 percent said the centers' coverage areas should vary to meet the need; 26 percent said they should be statewide; 15 percent said they should cover multi-state regions; and 8 percent said they should cover sub-state regions. When asked how many centers should be created, 41 percent said 10 to 50, while 24 percent said 50 to 100.

Many organizations are already involved in the work of helping clinics and physician offices with technology adoption, so they naturally see themselves as logical candidates to lead extension center efforts.

Some have argued that existing CMS Quality Improvement Organizations should take the lead. The Network for Regional Health Improvement suggests that ONCHIT give preference to regional health improvement collaboratives and chartered value exchanges for designation as regional extension centers. NRHI leaders argue that connecting health IT to quality improvements is critically important. "The strategy should demonstrate how the assistance given to providers will help to improve the quality and/or improve the efficiency of healthcare delivery in the region," NRHI wrote.

The National Association of Community Health Centers Inc. argues that Health Center Controlled Networks (HCCNs) and Primary Care Associations (PCAs) already provide an array of services to health centers and safety net providers, including health IT-related efforts listed as objectives of the regional centers.

The National Rural HIT Coalition is concerned the extension center effort may not place enough focus on rural providers. It proposes that at least one regional extension center be provided the funding to serve as a national rural HIT technical assistance and knowledge center. It also suggests that rural health clinics should be specifically noted as a prioritized provider to receive assistance from extension centers.

One thing these organizations seem to agree on is that the funding limits suggested could be harmful. They argue that the award amount averages of $1 million to $2 million may be insufficient to provide the on-site support described as the purpose of the regional extension centers. And the proposed maximum amount of $10 million to any one center may be too low. The New York eHealth Collaborative noted that the New York Primary Care Information Project and the Massachusetts eHealth Collaborative estimated that effective adoption required support services in the range of $10,000 per provider. "In light of this experience, the proposed maximum award of $10 million per regional extension center would limit the scale of operations and scope of clients that any single center can serve and would undermine its ability to effectively deliver the support services detailed in the draft description," the New York collaborative suggested.

In a recent interview, Phyllis Albritton described a multi-stakeholder collaboration forming in Colorado. Albritton is executive director of CORHIO, the statewide health IT entity that would play the role of umbrella organization.

"We were struck by the language that these should be shovel-ready. We have a number of quality initiatives in the state that are already working with the physician community on technology adoption," she said. "Rather than one organization being responsible, our intention is to apply through a collaboration of seven to nine groups that already have this expertise." Those groups include the Colorado Foundation for Medical Care, the Colorado Clinical Guidelines Collaborative and the Colorado Community Health Network, a primary care association.

"We have heard from the feds that they want this to get to work as quickly as possible and to engage as many stakeholders as possible, so this is the model we think will work," Albritton said. "Many of these groups will need funding to expand their capabilities, but they are already engaged."