Implementing Electronic Health Records: An Update Country: USA Partner Institute: Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management Survey no: (10)2007 Author(s): Petigara, Tanaz and Gerard Anderson Health Policy Issues: New Technology, System Organisation/ Integration, Political Context, Funding / Pooling, Quality Improvement, Remuneration / Payment, Responsiveness Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract In April 2004, President Bush announced his intent to provide Americans with electronic health records by 2014. The Office of the National Coordinator for Health Information Technology (ONCHIT) was established within the Department of Health and Human Services to develop and implement a strategic plan to guide this effort. This report provides an update on the progress of ONCHIT and HHS in meeting the President's objective. 2. Purpose of health policy or idea In July 2004, the Office of the National Coordinator for Health Information Technology (ONCHIT) and the Secretary of Health and Human Services (HHS) released the Framework for Strategic Action, which outlined 4 goals to advance the President's objective of providing Americans with electronic health records by 2014. The Government Accountability Office has been tracking the progress of ONCHIT and HHS. The following is a description of key actions and progress: Goal 1: Accelerate adoption of EHRs 1. The Certification Commission for Healthcare Information (CCHIT) was formed to develop a certification process for interoperable HIT products. CCHIT has certified 22 ambulatory care products. Ensuring the interoperability of HIT products reduces the risk of investment for physicians. 2. HHS issued new regulations which eased restrictions on physicians accepting donation of HIT products. 3. HHS awarded the Gulf Coast Electronic Digital Health Recovery contract to promote the use of EHRs in region affected by recent hurricanes. Providers are encouraged to implement EHRs as they rebuild the medical records of affected patients. 4. HHS awarded a contract to develop a standardized methodology to track the adoption of EHRs. The baseline for current EHR use was esttimated at 10 percent. Future progress will be compared to this baseline. Goal 2: Build an interoperable health information exchange infrastructure 1. The American National Standards Institute (ANSI) was awarded a contract to establish interoperability - 1 -
standards for HIT products. The standards recommended by ANSI will be intergrated into products used by federal health care delivery systems. 2. HHS awarded contracts to develop a Nationwide Health Information Network (NHIN). The NHIN will allow providers and consumers to access their health information even if the information is dispersed among disparate sources. Goal 3: Personalize health care by promoting Personal Health Records and consumer choice 1. Prototypes of the NHIN have functional requirements which will support personal health records. 2. Medicare beneficiaries have access to a beneficiary portal which allows them to view their claims, services and procedures, and benefits. Goal 4: Improve public health surveillance systems 1. Interoperability standards developed by ANSI include standards for sharing clinical information with public health agencies within 24 hours. 2. The Gulf Coast project will also facilitate the use of electronic health records by emergency responders. In 2005, the Secretary of HHS commissioned a Federal advisory body, the American Health Information Community (AHIC), to provide recommendations to HHS on achieving the President's goals. In 2008, the AHIC will transition into the private sector. HHS has also taken several steps to address privacy and security issues. For example, HHS has awarded contracts to 33 states and Puerto Rico to perform an assessment of state laws concerning privacy and security, and how they will affect the implementation of an interoperable health information exchange. However, the GAO found that HHS has not yet developed a comprehensive national strategy concerning privacy and security. Main objectives Provide interoperable Electronic Health Records to Americans by 2014; Develop a nation-wide health information exchange infrastructure; Empower consumers to manage their care; Improve public health surveillance systems. Type of incentives Financial and non-financial. Groups affected Providers, consumers, congress, insurers 3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial - 2 -
Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral EHR adoption in the United States lags behind that of other industrialized countries. Federal leadership is essential to accelerate adoption, but must be accompanied by funding to assist providers. 4. Political and economic background President Bush's goal of providing EHRs to Americans by 2014 is part of a national Technology Agenda to promote innovation and technology. Despite the known benefits of EHRs, their adoption in the United States has been slow compared to other countries due to high implementation costs for physicians, benefits which accrue mainly to payers and purchasers, and lack of interoperability. The strategies developed by ONCHIT/HHS address some of these barriers. Change based on an overall national health policy statement President Bush's Technology Agenda 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea The health care system in the United States faces several challenges including preventable medical errors, variations in health care quality, and administrative inefficiencies. President Bush's Technology Agenda was motivated in part by the recognition that HIT is an important tool in addressing many of these problems. Benefits to the consumer include reduction in medical errors, decrease in paperwork, higher quality care, and better access to personal health care information. The public health system will benefit from improved disease surveillance, quality measurement, and evaluation of programs and interventions. The goals of the President and HHS build on previous recommendations and projects by the Institute of Medicine, the National Committee on Vital and Health Statistics, and private foundations such as the Markle Foundation and the Robert Wood Johnson Foundation. Initiators of idea/main actors Government: The Bush administration initiated this policy, and continues to support a Federal role to accelerate the adoption of HIT in the United States. HIT receives bipartisan support from Democrat and Republicans in Congress. Providers: Concerned that it will add to costs and physicians will not be given adequate compensation. Hospitals want to control the process to increase market share. Payers: Insurers are supportive of EHRs but do not want to bear the full implementation costs for physicians; benefits come through increased administrative efficiency and care coordination, reductions in duplicate tests - 3 -
and medication errors. Patients, Consumers: Consumers are supportive of EHRs, but concerned about privacy and security of their health care information. Approach of idea The approach of the idea is described as: renewed: Public and private organizations have previously recommended implementing electronic health records. Innovation or pilot project Pilot project - In addition to this federal initiative, advances are also occurring at the State level. Massachusetts recently partnered with Blue Cross/Blue Shield in a $50 million effort to implement EHRs in 3 cities. Stakeholder positions Following President Bush's announcement, the Secretary of HHS and the National Coordinator released a report, "The Decade of Health Information Technology: Delivering Consumer-Centric and Information Rich Health Care - A Framework for Strategic Action". Congress and other stakeholders were supportive of this report. Actors and positions Description of actors and their positions Government President of the United States very supportive strongly opposed Congress very supportive strongly opposed Providers Physicians very supportive strongly opposed Hospitals very supportive strongly opposed Payers Insurers very supportive strongly opposed Patients, Consumers Consumers very supportive strongly opposed Influences in policy making and legislation The Wired for Health Care Quality Act 2005 was introduced and passed in the Senate, but could not be reconciled with the House version. The bill was reintroduced in the Senate in June 2007. It would codify the position and office of the National Coordinator for Health Information Technology. However, several features of the bill are not supported by the Bush Administration. In a letter to the Subcommitte on Health, Education, Labor, and Pensions (HELP), Secretary Leavitt opposed among others, retaining the AHIC in the public sector, and providing grants and loans to assist providers in adopting HIT. HELP has passed the bill, and it will now be considered by the full Senate. Legislative outcome pending Actors and influence Description of actors and their influence Government President of the United States very strong none - 4 -
Congress very strong none Providers Physicians very strong none Hospitals very strong none Payers Insurers very strong none Patients, Consumers Consumers very strong none Positions and Influences at a glance Adoption and implementation N/A Monitoring and evaluation The Wired for Health Care Quality Act 2007 will require that ONCHIT develop performance measures to evalute its progress. Recent GAO reports have found that ONCHIT currently lacks these measures. Review mechanisms n/a - 5 -
6. Expected outcome While progress has been made in several key areas, the GAO found that ONCHIT lacked detailed plans and performance measures needed to ensure that the President's goal will be met by 2014. It is unclear whether this goal will be achieved, or what can be expected by 2014. In addition, analysis of both the 2005 and 2007 bills by the Commonwealth Fund suggests that the funding required to accelarate the widespread adoption of HIT in the United States continues to be insufficient. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high There is growing evidence that electronic health care records can improve quality, improve efficiency, and control costs. This policy can have a significant impact on the U.S. health care system. 7. References Sources of Information Bates, D. "Physicians And Ambulatory Electronic Health Records". Health Affairs 24 (5) 2005. 1180-1189. Jha, A., Ferris, T., Donelan, K., DesRoches, C., Shields, A., Rosenbaum, S., and D. Blumenthal. "How Common Are Electronic Health Records in the United States? A Summary of the Evidence". Health Affairs Web Exclusive 496. October 2006. U.S. Department of Health and Human Services. Health Information Technology Initiative. Major Accomplishments: 2004-2006. No date. www.hhs.gov/healthit/news/accomplishments2006.pdf United States Government Accountability Office. Health Information Technology: HHS is Continuing Efforts to Define Its National Strategy. September 2006. United States Government Accountability Office. Health Information Technology: Early Efforts Initiated but Comprehensive Privacy Approach Needed for National Strategy. January 2007. The White House. Promoting Innovation and Competitiveness: President Bush's Technology Agenda. 2004. http://www.whitehouse.gov/infocus/technology/economic_policy200404/ innovation.pdf Anderson, GF., Frogner, BK., Johns, RA., and UE. Reinhardt. "Health care spending and use of information technology in OECD countries". Health Affairs 25(3) 2006 May-Jun. 819-31. Davis, K., Collins, S., and J. Kriss. An Analysis of Leading Congressional Health Care Bills: 2005-2007. Part II: Quality and Efficiency. The Commonwealth Fund. July 2007. Author/s and/or contributors to this survey Petigara, Tanaz and Gerard Anderson - 6 -
Suggested citation for this online article Petigara, Tanaz and Gerard Anderson. "Implementing Electronic Health Records: An Update". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/us/b10/3-7 -