Health Information Technology Policy in Texas

Statewide, Regional, and Constituency-Specific Initiatives

 Texas Medicine Magazine Logo  

Journal  - January 2009   

Tex Med . 2009;105(1):55-63.  

By Julie Graves Moy, MD, MPH  

Dr Moy, private practice physician, Austin, Texas, and doctoral candidate, The University of Texas School of Public Health. Send reprint requests to Julie Graves Moy, MD, MPH, 8126 Mesa Dr #B206-54, Austin, TX 78759; e-mail: .  


Electronic medical records and other health information technology are being touted as a solution to cost and quality issues in health care. Legislative and executive actions in Texas have been aimed at increasing the number of Texas physicians who use electronic medical records. Private sector solutions have been emphasized. Independent health information exchanges have been developed independently across the state, and some successful efforts to use government resources such as federally developed open source code have been implemented in private and public facilities. State agencies have developed and employ electronic medical records and health information exchange. Coordination and expansion of successful health information technologies has not occurred, and the risk of slow or no adoption is increased by a reluctance on the part of state government to provide direction and funding to the private sector in health care delivery in Texas or to allow private sector use of technologies developed by and in use by state agencies. 


Electronic exchange of health information is almost universally applauded, yet less frequently implemented. Numerous entrepreneurs, experts, pundits, and policy makers believe that many of the perceived problems with America's health care system (primarily quality and cost) will be repaired if American physicians and hospitals adopt electronic medical record (EMR) systems and other health information technology (HIT), and if patient-specific information is made available through electronic networks to any provider who is caring for a patient at a given time. 1-3 Others are more cautious, noting that while the use of EMRs is widespread in other Western nations, outcome studies have not shown the cost savings and quality improvement desired within the unique American health care system. 4-6 This issue is important because American providers of health care of all types, along with policy makers at local, state, and federal levels, are poised to invest substantial public and private dollars into HIT, hoping that the benefits will outweigh harms and the investment will yield systemwide cost savings.

In 2006, Texas Gov. Rick Perry joined national and state-level officials calling for widespread adoption of HIT. 7,8 He signed Senate Bill 45 (sponsored by Sen Jane Nelson and Rep Diane White Delisi), 9 which created the Health Information Technology Advisory Committee (HITAC) within the Texas Statewide Health Coordinating Council in the Department of State Health Services (DSHS).10 HITAC was charged with developing an HIT plan for Texas covering:

  • Electronic medical records;
  • Computerized clinical support systems;
  • Computerized physician order entry;
  • Regional health information exchange (HIE);
  • Other methods of incorporating information technology in pursuit of great cost-effectiveness and better patient outcomes; and
  • Price disparities in insurance coverage.

On September 29, 2006, HITAC issued the Roadmap for the Mobilization of Electronic Healthcare Information in Texas,11 outlining state and regional strategies and recommendations for HIT and HIE implementation.

Planning and policy development relating to HIT is also coordinated by the Texas Health Care Policy Council, created by House Bill 916 (introduced by Rep Beverly Woolley and Sen Jan Nelson) in 2005. The council aims to identify and address problems in Medicaid, including finding a way for HIT to decrease administrative costs and improve quality of care.

In October 2006, Governor Perry promulgated Executive Order RP-61 creating the Texas Health Care System Integrity Partnership (the Partnership), which followed closely the recommendations in the HITAC report. The Partnership was directed to:

  • Develop a governance and finance structure for a "new public-private collaborative" that would promote a "safe, high quality transparent and efficient health care system."
  • Develop a method for secure exchange of electronic health information, providing consumers with access to information on the price and quality of health care services and of health insurance in Texas, and
  • Find a way for the small-employer health insurance market in Texas to thrive.

Governor Perry appointed 15 Partnership members representing business, consumers, clinical laboratories, health plans, pharmacies, the pharmaceutical industry, pharmacy benefits managers, and physicians. Nonvoting members from state government include staff members from the Attorney General's Office, the Texas Health and Human Services Commission, DSHS, and the Texas Department of Insurance. Members of the governor's staff served as the Partnership's staff. Governor Perry directed the Partnership to follow these principles:

  • Be patient-centric,
  • Emphasize market-based solutions,
  • Engage stakeholders and limit government involvement,
  • Promote regional solutions, and
  • Proceed via incremental and evolutionary process.

The Partnership staff recommended creation of the Texas Health Information Network, which would establish statewide HIE capabilities for electronic laboratory results and delivery of medication history. The central entity would assist regional initiatives by identifying data and messaging standards for HIE and by identifying standards for streamlining health care administrative functions across payers and providers, including electronic patient registration and health plan enrollment status and benefits at the point of care. Staff presented options to the Partnership, including creation of the Texas Health Services Authority through statute or executive order or independently by a group of stakeholders. Staff also recommended the creation of a state-chartered public-private corporation and provided draft legislation to the Partnership.

The Partnership issued a report 12 on March 1, 2007, which included their decisions about the recommendations of the Governor's staff. The Partnership decided:

The establishment of a public-private partnership in the form of a state-chartered public corporation to promote the exchange of clinical data by providers and facilities could add value to the health care system. However, there are significant questions as to whether it could be financially self-sustaining. If Texas should create a state-chartered public corporation, its purpose should be to develop and operate a portal for health information exchange (HIE), and to provide technical support to promote the establishment and operations of regional HIE initiatives throughout the state.

The Partnership's report also noted that stakeholders were not convinced that widespread HIE adds value to the overall health system, that multiple regional HIE initiatives are better suited to Texas than a statewide entity, and that identifying a funding strategy should precede further investment by the state.

As the Partnership noted, the potential for viable regional or statewide HIE appears to be poor. Efforts in Texas and in other states to sustain HIE have failed after initial (usually grant) funding has been exhausted. European countries, most of which are a decade ahead of the United States in EMR and HIE use, invest public funds and require insurance company funding of HIT development, implementation, and operations. 13-15

This article assesses:

  • The current state of HIT adoption by selected public and private providers in Texas;
  • Public and private efforts to establish HIE systems;
  • The effect of the Partnership's recommendations on the equity, efficiency, and efficacy of the health system in Texas; and
  • Alternative policy directions at the federal level and in other states. 


The above-mentioned legislation, executive orders, and reports were reviewed. To assess HIT efforts by state and national governments, a literature search was conducted by using the National Library of Medicine, articles from the preceding three years of Health Affairs, Web sites of the National Organization of State Chief Information Officers and other state and federal agencies, and national news media coverage. To assess current state efforts, interviews were conducted with staff members of the Texas Academy of Family Physicians, the Texas Medical Association, Texas A&M's School of Rural Public Health, the Tarrant County Medical Society, and the Texas Medical Foundation Health Quality Institute. Additional information was obtained from a conference on HIT in rural and community hospitals (sponsored by the Texas Organization of Rural and Community Hospitals) and from lectures conducted by former Texas state Representative Ann Kitchen, Dr. A.K. Shah, and Dr. David Wanser as part of a Texas Health Policy course at the LBJ School of Public Affairs in Austin.  

 Barriers to HIT Use  

Physician groups in Texas have promulgated policy statements and resolutions supporting universal access to EMRs and for secure, privacy-assured access of critical and time-sensitive health information for emergency care, along with access to pertinent information in electronic format during office visits and elective hospital stays. However, only 12% to 27% of physician offices currently employ EMR systems. Use of EMRs by hospitals is variable, with most using electronic laboratory and x-ray result systems, some using scanned document management systems, and fewer using computerized order entry, nursing documentation, and physician progress notes. Connectivity between EMRs is limited to HIE efforts in a few regions.

Why has this widely available technology not found its way into physician offices and hospitals? And, why haven't networks been developed? A TMA survey of 1600 Texas physicians in October 2005 revealed that 45% planned to implement an EMR system, with 38% wanting to start the process within 1 to 2 years. Barriers to adoption of HIT included price, lack of interoperability, decrease in productivity, and the need for work flow and work place redesign.

Many physicians and hospitals have balked at purchasing EMR systems because of the cost. Small physician practices bear the bulk of the financial risk in implementing an EMR system. Patients do not demand them, and the largest financial value is gained by payers. Physicians have been reluctant to partner with hospitals, citing fear of possible violation of antikickback laws, concern over loss of freedom to admit or contract with other entities, and belief that costs will exceed initial estimates. Funding for effectiveness studies has been lacking. 16

Other barriers noted in the literature search and interviews included concerns about:

  • Information security and patient privacy. A cochair of a federal workgroup advising the Department of Health and Human Services on privacy resigned on February 21, 2007, citing concerns that privacy and security were not a priority for federal HIT planners. 17
  • Productivity losses. For example, Kaiser Permanente of California's $4 billion EMR system has encountered numerous technical problems, leading to alleged patient safety problems, patient identification errors, and slow-downs in care. 18
  • Lack of interoperability. Vendors of EMR software and hardware have been reluctant to adopt standards because of a fear of losing captive consumers.
  • Lack of HIT skills and resources. The skills needed to design and develop regional or local networks are scarce and expensive, and funding for network development and maintenance is even scarcer. 

Current State of HIT Use by Selected Public and Private Providers  

Some provider groups are working to overcome these barriers. TMA has a grant from the Physicians' Foundation to encourage EMR interoperability and to educate physicians about best practices in EMR adoption. The Physicians' Foundation was established in 2004 by settlement of the Aetna and CIGNA portions of organized medicine's federal antiracketeering lawsuits against some of the nation's largest for-profit HMOs.

In early 2007, TMA held a forum on the formation of regional health information organizations, bringing together stakeholders from RHIOs around the state. Harris, Dallas, Tarrant, and Smith counties and other regions have various levels of RHIO efforts under way, with TMA involvement in many cases. 19

State government is also involved in efforts to increase the number of physicians who use EMR systems. Senate Bill 1188 by Senator Nelson and House Bill 1771 by Representative Delisi directed the Health and Human Services Commission (HHSC) to implement certain reforms to improve the Medicaid program, including the use of an Austin-based EMR vendor (Catalis) to supply the hardware and software for a pilot program in physician offices "in lieu of supplemental rebates." Catalis was subsequently involved in litigation with several of its developers and directed some of its attention to ventures with network services provider Wayport. 20,21 A report on this pilot study could not be located.

Two Texas organizations, one public and one private, have taken advantage of the federal government's release of the VistA ( Veterans Health Information Systems and Technology Architecture) information system built around an EMR . Developed in the mid-1970s and used in 172 Veterans Affairs hospitals and 850 clinics, VistA is available under the Freedom of Information Act as open source code.

Midland Memorial Hospital has implemented a customized interface for VistA, the first in the United States in a private hospital, which cost $2.341 million for the first year. 22 Ongoing annual costs total $1.2 million. The 5-year return on investment, including error reduction and improved productivity, is expected to be $6.172 million. Note that the physicians at the hospital continue to use dictation and transcription services.

Texas Tech University Health Sciences Center School of Medicine was the first medical school in the United States to implement an office EMR system built on VistA in January 2007. The Family Medicine Department module is fully operational, and development has begun on links between clinics and with hospitals. Dr. Mary Spalding, the Family Medicine Department chair, notes VistA's ability to assist departments in disease registries and decision support. 23

Texas hospitals are involved in HIT and EMR systems to varying degrees. In Texas in 2006, the median capital spending per bed for hospital HIT system implementation was $5,556, while the median operating cost per bed was $12,060. 24 Larger hospitals are pushing forward with HIT development plans, but many smaller facilities are finding HIT out of reach. Some small facilities are taking advantage of federal programs; others do not have the local expertise to participate. For example, the Medicare Rural Hospital Flexibility Program, created in 1997 by Congress, allows critical access hospitals to receive funding from grants passed through state offices to implement initiatives to strengthen rural health care infrastructure. 25 In March 2006, 95% of Texas critical access hospitals reported the use of computers for administrative and financial transactions, 21% have some EMRs, and 51% access clinical guidelines and critical pathways electronically, usually by Internet. Half of these hospitals have formal information technology plans, and three-fourths have budgeted funds for buying HIT. Ninety-eight percent have broadband Internet access. 26

This widespread presence of broadband access reflects the advancement in commercial Internet networks. Small Texas hospitals have also benefitted from state funding through Telecommunications Infrastructure Fund (TIF) grants, which provided T1 internet lines to the hospitals. 27 Members of the Texas Organization of Rural and Community Hospitals (TORCH) have access to full T1 broadband Internet for $470/month. More than $500,000 in subsidy TIF funds is paid to Texas hospitals each year. While Governor Perry repealed the TIF grant program in 2003, the legislature continued the fee during that session and in 2005. Currently, $210 million a year in revenues are generated from these fees. 28 TORCH also provides security risk assessment for its member hospitals interested in HIT. 29

A session of TORCH's 2007 Health IT conference discussed the development of a statewide Internet-based network for transmission and storage (in Austin) of x-rays with their reports; some rural hospitals are currently participating. The advantage to members is that radiologists can access x-ray images to read and interpret without driving to the facility. Many small and rural hospitals do not have access to radiologists who work on site. 30 A shortage of available radiologists is driving up their market value; in 2003, radiologists were the most highly recruited of the medical specialties. 31

An earlier health information technology - telemedicine - is still active in parts of the state. All seven of Texas' health science centers have developed extensive telemedicine networks. Texas Tech University Health Sciences Center uses live interactive video in health care, as well as many clinical applications of telemedicine at its clinics, in rural areas, and in correctional facilities. The University of Texas Medical Branch in Galveston also has numerous telemedicine projects in rural areas, in correctional facilities, and in clinics in East Texas. 32   

Current State of HIE Systems  

Many regional HIE efforts are progressing, some within state agencies. Among them are miRHIO, the Behavioral Health Integrated Provider System (BHIPS), the Indigent Care Coalition, and ImmTrac. 

In Southeast Texas, the HIE miRHIO was started with funding from federal Health Resources and Services Administration (HRSA) grants. Consisting of seven hospitals, two corporations, and 200 physicians in eight counties, this HIE has a centralized data repository in Austin, connectivity among all members, "smart cards" for 35,000 patients, and a Web-accessible patient portal. The start-up budget was $1 million over three years, and ongoing operations are funded by fees from each hospital. Physicians are offered the benefit of credit card and check processing for patients' copayments and fees, as well as managed care contracting. Hospitals benefit from access to patients' test results with a reduction in duplicative testing and the associated costs. The system is scalable and replicable and uses industry-standard interoperable data sets based on the federally recognized national standard Continuity of Care Record. The hospitals in miRHIO are:

  • Brazosport Regional Health System, Lake Jackson,
  • Columbus Community Hospital, Columbus,
  • DeTar Healthcare System, Victoria,
  • Driscoll Children's Hospital, Corpus Christi,
  • Jackson Healthcare System, Edna,
  • Lavaca Medical Center, Hallettsville, and
  • Memorial Medical Center, Port Lavaca. 33

Texas is the site of the first statewide EMR system in the United States. The BHIPS is an Internet-based, nonproprietary computer system that allows behavioral health providers to report on care and to bill online. Winner of the 2006 Davies Award for public systems from the Healthcare Information and Management Systems Society (HIMSS), its security features allow access of data by providers only with consent of the patient. Starting with patients in substance abuse programs, collaboration between the federal government and DSHS via a federal Transformation Grant has resulted in 325,000 complete health records in the system. Another HIT innovation in Texas' public mental health sector is the Dallas-area NorthSTAR managed mental health program, which uses Internet messaging technology for instant searches of a regional data base of all Medicaid, mental health, and substance abuse patients in a jail diversion program. Also, the health science center in San Antonio is connecting with local community mental health centers, and in other parts of Texas, local mental health/mental retardation centers are collaborating with federally qualified health centers on information exchange efforts (D. Wanser, LBJ School of Public Affairs, oral communication, March 2007).

In its 10th year, Austin's Indigent Care Coalition has developed an HIE for the region by using HRSA and private funding. This system is designed to give safety-net providers the tools to leverage resources collaboratively and to reduce costs, while building community capacity and increasing revenues. Access to care and efficiencies are the focus of this project, which encompasses Williamson, Hays, and Travis counties, with some efforts beginning in Burnet, Caldwell, and Bastrop counties. This collaboration of providers used federal and private grant funding to develop ICare, a shared health history and information exchange for patients that facilitates both program evaluation and clinical care. A Web-accessible data base at all clinics and hospitals in the program allows screening for eligibility for state and local programs. Efforts to develop centralized scheduling are under way. As of December 2006, the system was being used at 47 locations (13 hospitals, 31 clinics, 1 mental health authority, and 2 physician networks), included records for 628,312 patients, had recorded 2.5 million encounters from 2002, and had stored 426,298 prescriptions. ICare is not a full EMR system. Providers wanted only key health information to facilitate care 34 (A. Kitchen, LBJ School of Public Affairs, oral communication, February 2007).

DSHS houses ImmTrac, a statewide voluntary immunization registry for children. State Rep Donna Howard, of Austin, sponsored a bill in the 80th legislative session to expand this registry for all Texans, but it did not become law. ImmTrac provides Internet-based access for physician offices, clinics, and hospitals to check on the immunization status of any Texan who chooses to be in the system.

Texas A&M's School of Rural Public Health secured a grant from the federal Agency for Healthcare Quality and Research to support small, rural, critical access hospitals in the use of software to analyze quality data and comply with Medicare data-reporting projects in the federal Hospital Quality Improvement Project. A Web portal, data analysis software, and hospital staff education are hoped to improve quality and safety in these facilities. Grant partners include the TMF Health Quality Institute and the Dallas-Fort Worth Hospital Council. 35

In North Texas in 2006, the Dallas County Medical Society, the Dallas-Fort Worth Hospital Council, and the Tarrant County Medical Society were awarded a $500,000 planning grant from The University of Texas system to create an RHIO 36 (R. Sloane, Tarrant County Medical Society, oral communication, November 2006).

Also, Texas was awarded $4 million in federal funds to develop an HIE "passport" for the 30,000 children in foster care. Superior Health Plan is implementing this program. 37 Several major hospital systems are developing integrated EMR systems by using a single vendor (although few are linking to each other), and the University Health System, San Antonio, is developing a bilingual HIE for patients with diabetes. 

The Effect of the Partnership's Recommendations on Health System Equity  

Major stakeholders involved in the HIT policy discussion include HIT vendors, patients, physicians, hospitals, insurance companies, and state and federal governments. The "winners and losers" discussion about spending on HIT is multifaceted. Vendors have much to gain in the sale of products and services. Patients could gain in improved quality of care and potential lower costs, but could find that quality in some cases may worsen 6 and that costs may not decline. Some studies have found that office-based EMRs may lead to higher billings and decreased provider productivity, with no savings in cost or liability insurance premiums even if error rates decrease. 4 Hospitals also have mixed results with respect to return on investment. The biggest potential winners are insurers and employers, who could reap the benefits of cost savings without making investments. Governments could gain or lose, depending on how much they invest and what actual health outcomes result. RAND estimated the potential savings from national HIE to be $77.8 billion annually (5% of all health care spending in 2003), but reported that most of this would not go to the providers who buy the necessary software and equipment. 38        

The Partnership's approach leans heavily on the idea that the market will lead to the best outcomes. It recommended minimal to no state funding to private providers for the purchase of HIT software and equipment or for sustaining regional HIE systems. The Partnership's focus on regional and private-sector solutions leaves Texans with a problem familiar to other aspects of the health care system in the United States, ie, the individual patient and the small provider bear disproportionate costs and cannot create economies of scale. The cost of implementing and using EMR and HIE systems is borne by the provider, but the cost savings are enjoyed by the employer, insurers, or governmental payers. Texas is unlikely, if these recommendations are followed, to provide needed leadership and infrastructure for maximal efficiency of public-sector and nonprofit-sector resources. Also, with a focus on regional solutions, widely varying regional efforts are likely to ensue, and health inequity in Texas is likely to worsen.

Others have likened these complex information networks to railroads and highways, noting that multiple relationships and sometimes government power are needed to create working systems. 39 For example, because insurers are likely to be the greatest beneficiaries of HIE from a financial standpoint, government could tax or assess "user fees" to gain participation by the insurer in the funding of HIT development. 

The Effect of the Partnership's Recommendations on Health System Efficiency  

Adoption of EMRs may lead to lower productivity in physician practices. Offsetting this are potentially faster and more accurate processing of health insurance claims and reduction of duplicative testing, among other benefits.

The Partnership recommends minimal state action and investment, expecting instead that multiple regional solutions will develop. This approach could be quite inefficient. Lack of state-level leadership means that some parts of the state will never have integrated systems, while others will "reinvent the wheel" and miss out on savings from lessons learned by others in the state. 

The Effect of the Partnership's Recommendations on Health System Efficacy  

The Partnership's report doubted that any statewide network could be self-sustaining financially. If Texas did create a state-chartered, public, nonprofit corporation to house this information exchange, as staff recommended, its purpose would be to develop and operate a portal for HIE and to provide technical support. It would not, however, actually provide the exchange services. Note that in September 2006 HITAC recommended the formation of a legislatively chartered nonprofit corporation that would provide this clearinghouse function, just the opposite of the Partnership's recommendation.

Projects such as miRHIO and ICare in Texas and efforts in other states have identified data elements, technology standards, and processes that work. A poorly funded state-owned portal could result in best practices not followed. Building an unwieldy system with traditional state bidding processes and potential outsourcing could lead to problems such as those faced by the Texas Health and Human Services Commission. 40   

Alternative Policy Directions  

Alternatives to the path recommended by HITAC and the Partnership can be developed by examining efforts by the federal government and by other states. To date, many of the successful Texas efforts have been supported by federal grants.

Many states are in advanced stages of HIE systems development. The National Association of State Chief Information Officers has catalogued state initiatives and notes that Texas, unlike many states, has no chief information officer. 41 More than half of states either have initiatives or plans, and 17 states have grant or contract funding in place. 42 For example, the Florida Health Information Infrastructure Advisory Board was established to advise and support the state's Agency for Health Care Administration as it develops and implements a strategy for the adoption and use of EMRs and creates a plan to promote the development and implementation of a Florida health information infrastructure, including measures to promote greater adoption of EMR information systems among the state's health care providers.

In late 2006, California's RHIO published a request for proposals for a statewide HIE, expecting to spend $100 million for a "utility-like infrastructure" for health care data in California. 43   

Recommendations for Texas Policy Makers  

HITAC had an advisory panel of stakeholders and state funding, along with office space at DSHS. A chief health care information officer for the state could be housed there; he or she would need an adequate staff and budget to manage a central repository of information about state and federally funded HIT programs in Texas and elsewhere in the country. Neither the HITAC report nor the Partnership report discusses existing initiatives in Texas. One alternative approach would have been to catalog existing federal, state, local government, and privately funded initiatives already under way; assess their "scalability" to larger regions or even statewide; and assess whether replication is likely to succeed. HITAC could then provide referral and coordination services for interested regional entities.

Federal grants for HIT are generally intended to fund projects that, if successful, will be replicated. Texas should benefit from this federal money invested in the state by promulgating information about successful programs to other potential participants. HITAC should also study the options for scalability and replicability of successful projects and analyze the return on investment for the state for various strategies for investment, ie, whether regional, statewide, or a combination would be the best use of public funds for a system that reaches all Texans.

HITAC's statewide efforts should focus on interoperability and sustainability of funding and on coordinating and pooling the efforts of the various state agencies with local and regional efforts to generate maximum "pull-down" of federal dollars to Texas. Programs in the Office of Rural and Community Affairs, the Agricultural Extension, the federal and state prisons, substance abuse services, the NorthSTAR managed mental health program, federally funded community health centers, federally qualified health centers, rural health clinics, and perhaps others should coordinate efforts and share successes and lessons learned. HITAC could serve as a resource for any Texas entity, public or private, providing referrals to experts who have successfully implemented and sustained HIT initiatives or HIE systems or both.

Other possibilities include a Medicaid waiver (such as in Iowa) substantiated by plans to replicate or scale up successful projects such as ICare in Austin or miRHIO in Southeast Texas. Texas Tech and Midland Hospital's successful implementation of VistA could be adopted by the state, rewarding these providers for their innovation by sharing savings to state programs with them or referring other entities that could pay for consulting services from these successful implementers (or the state could pay them). Ongoing evaluation, using models such as those previously tested at the schools of public health in Houston (and its Austin campus) and in College Station could provide valuable information to policy makers, while affording opportunities for education within these institutions.

Working statewide RHIOs, such as the Indiana Health Information Exchange 44,45 the Massachusetts Health Data Consortium, 46 and the new California RHIO, should be studied for applicability to Texas. Current Texas efforts in disaster preparedness and in epidemiology and biosurveillance should be coordinated with HIE efforts, and funding streams should be tapped for infrastructure and planning funds that could be dual-purposed (A.K. Shah, LBJ School of Public Affairs, oral communication, April 2007). 47-49

The Partnership and HITAC discuss regional solutions but do not discuss boundaries of regions. Outside of urban counties and hospital districts, a logical starting point for defining regional boundaries within the state is the existing public health regions; another option is to define "catchments" around each of the state's academic health centers (as was begun with telemedicine planning). This allows other state-funded telecommunications infrastructure to serve dual purposes during planning efforts.

The focus of the Partnership and the governor on market solutions is likely to lead to insufficient coordination of efforts for statewide coverage by HIT. A concern about bringing so many private-sector stakeholders into an advisory capacity to both HITAC and the Partnership is that vendors will sell unneeded items to public entities. This situation did arise during the growth of telemedicine efforts and is a risk if stakeholders have too much access to the decision-making process. Any alternative solution should first assess whether a problem exists and, if so, whether the solution solves the particular problem. Texas policy makers have, in the past, rushed to adopt technology as a solution to a problem that was not clearly present.

Texas policy makers should realistically match their expectations with financial realities. For parts of Texas, especially poorer regions, regional solutions are unlikely to begin without state investment. Even in more affluent parts of the state, sustainability of HIE will likely need some public contribution if long-term financial viability is to occur. The business model for an RHIO has not been sustainable since efforts began in the mid-1990s. All 200 RHIOs in the United States require contributions from government or philanthropy. Planning, legal fees, operating costs, and hardware and software purchase require substantial investment. Participants often have unequal resources and disparate interests. 50

Finally, Texas policy makers should read past the headlines. Hillestad's widely cited article on the potential cost savings to be had with widespread adoption of HIT has an important caveat in the text: savings are unlikely without related changes to the health system, including adequate financial rewards for providers who adopt HIT and adequate access to affordable health insurance to enable most patients to obtain primary and preventive care. 1   


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