Health Information Technology
HHS Is Taking Steps to Develop a National Strategy Gao ID: GAO-05-628 May 27, 2005To prevent medical errors, reduce costs, improve quality, and produce greater value for health care expenditures, President Bush has called for the Department of Health and Human Services (HHS) to develop and implement a strategic plan to guide the nationwide implementation of health information technology (IT) in both the public and private health care sectors. The Departments of Defense (DOD) and Veterans Affairs (VA), along with other countries, have already taken steps to improve health care delivery and administration by implementing IT solutions. GAO was asked to provide an overview of HHS's recent efforts to develop a national health IT strategy for realizing the President's vision, and to identify lessons learned from DOD's, VA's, and other countries' experiences in implementing health IT.
The Secretary of HHS appointed the National Coordinator for Health IT in May 2004. In July 2004, the national coordinator released a framework for strategic action, which outlines four goals and 12 strategies to guide the development of a full strategic plan for national health IT adoption. The framework builds upon already-existing work in federal health IT and includes plans to identify and learn from agencies' experiences. It also describes actions to be taken by both the public and private sectors to achieve interoperability in health IT across the nation. HHS plans to address the goals and strategies of the framework with a three-phased approach over a number of years and is currently implementing phase I of the framework. However, HHS has not established milestones for the completion of phase I activities nor has it made detailed plans or set milestones for the completion of activities for phases II and III. GAO identified lessons learned from DOD and VA that could provide valuable insight to HHS as it works toward implementing a national health IT infrastructure. DOD and VA operate the largest health care delivery networks in the nation, and important lessons can be taken from their experiences in health IT. Additionally, other countries have begun initiatives to establish national health IT infrastructures. DOD, VA, Canada, Denmark, and New Zealand provided GAO with valuable lessons learned that can be applied to the United States's efforts. Among other lessons learned, they reported the need to obtain the endorsement of top leadership, define and adopt standards, address the needs of stakeholders, and deploy IT solutions in small increments and build on successes.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-05-628, Health Information Technology: HHS Is Taking Steps to Develop a National Strategy
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Report to the Chairman, Committee on the Budget, House of
Representatives:
May 2005:
Health Information Technology:
HHS Is Taking Steps to Develop a National Strategy:
GAO-05-628:
GAO Highlights:
Highlights of GAO-05-628, a report to the Chairman, Committee on the
Budget, House of Representatives:
Why GAO Did This Study:
To prevent medical errors, reduce costs, improve quality, and produce
greater value for health care expenditures, President Bush has called
for the Department of Health and Human Services (HHS) to develop and
implement a strategic plan to guide the nationwide implementation of
health information technology (IT) in both the public and private
health care sectors. The Departments of Defense (DOD) and Veterans
Affairs (VA), along with other countries, have already taken steps to
improve health care delivery and administration by implementing IT
solutions. GAO was asked to provide an overview of HHS‘s recent efforts
to develop a national health IT strategy for realizing the President‘s
vision, and to identify lessons learned from DOD‘s, VA‘s, and other
countries‘ experiences in implementing health IT.
What GAO Found:
The Secretary of HHS appointed the National Coordinator for Health IT
in May 2004. In July 2004, the national coordinator released a
framework for strategic action, which outlines four goals and 12
strategies to guide the development of a full strategic plan for
national health IT adoption (see table below). The framework builds
upon already-existing work in federal health IT and includes plans to
identify and learn from agencies‘ experiences. It also describes
actions to be taken by both the public and private sectors to achieve
interoperability in health IT across the nation.
HHS plans to address the goals and strategies of the framework with a
three-phased approach over a number of years and is currently
implementing phase I of the framework. However, HHS has not established
milestones for the completion of phase I activities nor has it made
detailed plans or set milestones for the completion of activities for
phases II and III.
Goals and Strategies of HHS‘s Framework for Strategic Action:
Goals: Goal 1: Inform clinical practice with the use of electronic
health records (EHR);
Strategies[A]: 1. Incentivize EHR adoption.
Goals: Goal 1: Inform clinical practice with the use of electronic
health records (EHR);
Strategies[A]: 2. Reduce risk of EHR investment.
Goals: Goal 1: Inform clinical practice with the use of electronic
health records (EHR);
Strategies[A]: 3. Promote EHR diffusion in rural and underserved areas.
Goals: Goal 2: Interconnect clinicians so that they can exchange health
information using advanced and secure electronic communication;
Strategies[A]: 1. Foster regional collaboration.
Goals: Goal 2: Interconnect clinicians so that they can exchange health
information using advanced and secure electronic communication;
Strategies[A]: 2. Develop a national health information network.
Goals: Goal 2: Interconnect clinicians so that they can exchange health
information using advanced and secure electronic communication;
Strategies[A]: 3. Coordinate federal health information systems.
Goals: Goal 3: Personalize care with consumer-based health records and
better information for consumers;
Strategies[A]: 1. Encourage use of personal health records.
Goals: Goal 3: Personalize care with consumer-based health records and
better information for consumers;
Strategies[A]: 2. Enhance informed consumer choice.
Goals: Goal 3: Personalize care with consumer-based health records and
better information for consumers;
Strategies[A]: 3. Promote use of telehealth systems.
Goals: Goal 4: Improve public health through advanced biosurveillance
methods and streamlined collection of data for quality measurement and
research;
Strategies[A]: 1. Unify public health surveillance architectures.
Goals: Goal 4: Improve public health through advanced biosurveillance
methods and streamlined collection of data for quality measurement and
research;
Strategies[A]: 2. Streamline quality and health status monitoring.
Goals: Goal 4: Improve public health through advanced biosurveillance
methods and streamlined collection of data for quality measurement and
research;
Strategies[A]: 3. Accelerate research and dissemination of evidence.
Source: HHS.
[A] Phase I strategies are shown in bold type.
[End of table]
GAO identified lessons learned from DOD and VA that could provide
valuable insight to HHS as it works toward implementing a national
health IT infrastructure. DOD and VA operate the largest health care
delivery networks in the nation, and important lessons can be taken
from their experiences in health IT. Additionally, other countries have
begun initiatives to establish national health IT infrastructures. DOD,
VA, Canada, Denmark, and New Zealand provided GAO with valuable lessons
learned that can be applied to the United States‘s efforts. Among other
lessons learned, they reported the need to
* obtain the endorsement of top leadership,
* define and adopt standards,
* address the needs of stakeholders, and
* deploy IT solutions in small increments and build on successes.
What GAO Recommends:
To accelerate the adoption of interoperable IT for health care, GAO
recommends that the Secretary of Health and Human Services establish
and follow detailed plans and set milestones for each phase of HHS‘s
framework for strategic action.
In commenting on a draft of this report, DOD, HHS, and VA concurred
with our results; HHS agreed with our recommendation. Technical
comments were incorporated in this report as appropriate.
www.gao.gov/cgi-bin/getrpt?GAO-05-628.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact David A. Powner, (202)
512-9286, pownerd@gao.gov.
[End of section]
Contents:
Letter:
Recommendation for Executive Action:
Agency Comments:
Appendixes:
Appendix I: National Health Information Technology Strategy:
Appendix II: Comments from the Department of Health and Human Services:
Appendix III: Comments from the Department of Veterans Affairs:
Abbreviations:
AHRQ: Agency for Health Research and Quality:
CDC: Centers for Disease Control and Prevention:
CHI: Consolidated Health Informatics:
CMS: Centers for Medicare and Medicaid Services:
DOD: Department of Defense:
EHR: electronic health records:
FDA: Food and Drug Administration:
FHA: Federal Health Architecture:
HHS: Department of Health and Human Services:
HRSA: Health Resources and Services Administration:
IHS: Indian Health Service:
IT: information technology:
NCVHS: National Committee on Vital and Health Statistics :
NHIN: National Health Information Network:
NIH: National Institutes of Health:
ONCHIT: Office of the National Coordinator for Health IT:
VA: Department of Veterans Affairs:
Letter May 27, 2005:
The Honorable Jim Nussle:
Chairman, Committee on the Budget:
House of Representatives:
Dear Mr. Chairman:
According to the Institute of Medicine, health care delivery in the
United States has long-standing problems with medical errors and
inefficiencies that increase health care costs. The U.S. health care
delivery system is an information-intensive industry that is complex
and highly fragmented with estimated spending of $1.7 trillion in 2003.
In April 2004, President Bush announced a health information technology
(IT) plan that calls for the development and implementation of a
strategic plan to guide the nationwide implementation of health IT in
both the public and private health care sectors to prevent medical
errors, improve quality, and produce greater value for health care
expenditures.
Also in April 2004, the President issued an executive order that
required the Secretary of Health and Human Services to appoint a
national coordinator whose role is to provide leadership for the
development and nationwide implementation of an interoperable health IT
infrastructure to improve the quality and efficiency of health care.
The National Coordinator for Health IT was appointed in May 2004; in
July 2004, the coordinator released a framework for strategic action,
the first step toward a national strategy. The framework builds upon
already-existing work in federal health IT and includes plans to
identify and learn from agencies' experiences, including those of the
Departments of Defense (DOD) and Veterans Affairs (VA), which operate
the largest health care delivery networks in the nation and have
experience with developing and implementing IT solutions throughout
their systems. Additionally, other countries have begun to develop and
implement strategies to improve health care delivery through the
nationwide adoption of IT and can provide valuable lessons for the
Department of Health and Human Services (HHS).
You asked us to (1) provide an overview of HHS's efforts to develop and
implement a national health IT strategy, (2) identify lessons learned
from DOD's and VA's experiences with implementing electronic health
records, and (3) identify lessons learned from other countries' efforts
to modernize health IT infrastructures. We conducted work at HHS, DOD,
and VA--the federal agencies that play major roles in supporting and
providing health care delivery in the United States and that are
promoting the use of health IT. We reviewed and assessed HHS's
framework and plans for developing a national health IT strategy to
understand the role of the new office for national coordination of
health IT. We supplemented our assessment by discussing with officials
throughout the department their involvement in national efforts to
implement health IT and the integration of current health IT
initiatives into the national strategy. We analyzed DOD and VA
documentation and prior GAO reports discussing the two departments'
implementation of health IT (see app. I). We supplemented our analyses
by discussing with DOD and VA officials the lessons that they learned
from implementing health IT solutions in two of their major information
systems. We selected examples of other countries' efforts to modernize
health IT infrastructures based upon literature reviews and discussions
with health care IT experts. We discussed with Canada, Denmark, and New
Zealand their initiatives to modernize national health IT
infrastructures and identified lessons learned from their experiences
that could be meaningful to the United States's efforts. We conducted
our work from October 2004 through March 2005, in accordance with
generally accepted government auditing standards.
On April 1, 2005, we provided your office with a briefing on the
results of this review. The purpose of this letter is to provide the
published briefing slides to you, which appear as appendix I. The
information in these slides has been updated to include additional
information requested by your office.
In summary, we found that HHS, through the Office of the National
Coordinator for Health IT, is taking initial steps toward developing a
national strategy for health IT and has released a framework that
describes actions to be taken by the public and private sectors to
develop and implement such a strategy. The framework defines goals and
strategies that are to be implemented in three phases. Phase I focuses
on the development of market institutions[Footnote 1] to lower the risk
of health IT procurement, phase II involves investment in clinical
management tools and capabilities, and phase III supports the
transition of the market to robust quality and performance
accountability.
HHS is in the initial phase of implementing activities to achieve the
goals of the framework and, as a result, has made progress toward
coordinating federal health IT efforts and reaching out to private
industry. For example, in November 2004, the department issued a
request for information seeking public input and ideas for developing a
national health information network; a task force of federal agencies
is evaluating over 500 responses to this request. HHS is also working
with the private sector to develop standards and certification
procedures for health IT interoperability. However, HHS has not
established milestones for the completion of phase I, nor has it
defined plans for phases II and III. Without defined milestones, it
remains unclear when the important activities of phase I will be
completed to provide the building blocks needed to support the
activities of the subsequent phases.
We identified lessons learned from DOD and VA that could provide
valuable insight to HHS as it works toward implementing a national
health IT infrastructure. DOD and VA operate the largest health care
delivery networks in the nation, and important lessons can be taken
from their experiences in health IT. Among other things, they reported
the need to:
* obtain full endorsement of top leadership,
* define and adopt common standards and terminology,
* recognize and address the needs of the varied stakeholder
communities, and:
* deploy in small increments and build on success.
We also reported additional lessons learned from other countries'
experiences in modernizing health IT infrastructures. Canada, Denmark,
and New Zealand have begun initiatives to establish national health IT
infrastructures with government support and identified lessons learned
from their experiences, such as:
* focus on creating standards first,
* establish a central organization to lead health IT efforts, and:
* implement solutions incrementally.
Recommendation for Executive Action:
As a result of our work, we recommend that the Secretary of Health and
Human Services establish detailed plans and milestones for each phase
of the framework for strategic action and take steps to ensure that
those plans are followed and milestones are met.
Agency Comments:
We received written comments on a draft of this report from the Acting
Inspector General at HHS and the Deputy Secretary of VA. We received
oral comments from the Chief Enterprise Architect for Military Health
System at DOD. DOD, HHS, and VA concurred with our results and provided
technical comments, which we have incorporated in this report as
appropriate. HHS agreed with our recommendation and described
additional actions that the Secretary is taking to achieve specific
goals of the framework and to benefit from lessons learned from DOD and
VA. HHS also provided additional information about the steps that the
department is taking to lead the nation in health IT efforts. This
information is provided in HHS's written comments, which are reproduced
in appendix II. VA's written comments are reproduced in appendix III.
We are sending copies of this report to the Chairmen and Ranking
Minority Members of other Senate and House committees and subcommittees
having authorization and oversight responsibilities for health care IT.
We are also sending copies to the Secretary of Health and Human
Services and to the other agencies that participated in our review. We
will also make copies available to others upon request. In addition,
the report will be available at no charge on the GAO Web site at
[Hyperlink, http://www.gao.gov].
Should you or your office have any questions about matters discussed in
this report, please contact Dave Powner at (202) 512-9286 or by e-mail
at [Hyperlink, pownerd@gao.gov]. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. Major contributors to this report also included
Tonia D. Brown, Pamlutricia Greenleaf, M. Saad Khan, Valerie C. Melvin,
Teresa F. Tucker, and Jessica D. Waselkow.
Sincerely yours,
Signed by:
David A. Powner:
Director, Information Technology Management Issues:
Signed by:
Linda D. Koontz:
Director, Information Management Issues:
[End of section]
Appendixes:
Appendix I: National Health Information Technology Strategy:
National Health Information Technology Strategy:
Briefing for Majority Staff:
Committee on the Budget:
House of Representatives:
April 1, 2005:
Updated:
Table of Contents:
Introduction:
Objectives, Scope, and Methodology:
Results in Brief:
Background:
National Health Information Technology Strategy:
Lessons Learned from the Departments of Defense and Veterans Affairs:
Lessons Learned from Other Countries:
Conclusions:
Recommendation:
Agency Comments:
Appendixes:
Introduction:
The United States health care delivery system is an information-
intensive industry that is complex, inefficient, and highly fragmented,
with estimated spending of $1.7 trillion in 2003.
Calling for transformational change in the health care industry, the
Institute of Medicine pointed out that health care delivery in the
United States has longstanding problems with medical errors and
inefficiencies that increase the cost of health care.[NOTE 1]
The President's health care information technology (IT) plan calls for
the development and implementation of a strategic plan to guide the
nationwide implementation of interoperable health information
technology in both the public and private health care sectors that will
prevent medical errors, reduce costs, improve quality, and produce
greater value for health care expenditures.
NOTE:
[1] Institute of Medicine, To Err Is Human: Building a Safer Health
System (Washington, DC: November 1999) and Crossing the Quality Chasm:
A New Health System for the 21st Century (Washington, D.C.: March
2001).
Objectives, Scope and Methodology: Objectives and Scope:
Objectives:
To provide an overview of the Department of Health and Human Services'
(HHS) efforts to develop and implement a national health information
technology strategy.
To identify lessons learned from the Departments of Defense's (DOD) and
Veterans Affairs' (VA) implementation of electronic health records
(EHRs).
To identify lessons learned from other countries' efforts to modernize
health IT infrastructures.
Scope:
Conducted work at HHS components that play major roles in supporting
health care IT, including the Agency for Healthcare Research and
Quality, Centers for Medicare and Medicaid Services, Food and Drug
Administration, Health Resources and Services Administration, Indian
Health Service, National Institutes for Health, and Office of the
National Coordinator for Health IT in Washington, D.C., and the Centers
for Disease Control and Prevention in Atlanta, GA:
Conducted work at DOD's Office of Health Affairs in Falls Church, VA
and VA's Veterans Health Administration in Washington, D.C.
Selected and reviewed examples of health care IT infrastructure
initiatives from Canada, Denmark, New Zealand, and the United Kingdom.
Objectives, Scope and Methodology: Methodology:
Reviewed HHS's framework and implementation plans for developing a
national health IT strategy and held discussions with agency officials
about their involvement in national efforts to implement health IT and
the integration of current health IT initiatives into the national
strategy.
Analyzed agency documentation and GAO reports discussing DOD's and VA's
implementation of EHRs as part of the Composite Health Care System II
and the Veterans Health Information System and Technology Architecture:
* Supplemented analyses with interviews of DOD and VA officials
regarding the agencies' practices, processes, and outcomes in
implementing EHRs, and identified related lessons learned that could be
useful in the implementation of a national health care system.
* Consulted with a private health care consultant currently studying
EHRs to assess the validity of the identified lessons and their
applicability in federal and private health care settings.
Conducted literature reviews of other countries' efforts to implement
health IT and held discussions with officials in Canada, Denmark, and
New Zealand to gain information about experiences related to costs,
benefits, time frames, and challenges:
* We held discussions with health care IT experts and reviewed
literature to identify countries that are modernizing health IT
infrastructures and were willing to discuss their initiatives and
lessons learned with us.
* We obtained information about the United Kingdom's health IT
modernization project by reviewing publicly available documentation.
We conducted our work from October 2004 through March 2005 in
accordance with generally accepted government auditing standards.
We collected systems descriptions and cost information from agency
officials and did not independently verify data provided to us.
We requested comments from HHS, DOD, and VA on a draft of these
briefing slides.
Results in Brief:
In July 2004, HHS delivered a framework for strategic actions as a
first step toward a strategy to implement a nationwide health IT
infrastructure that involves both the public and private sectors'
participation.
* The framework builds upon ongoing work in federal health IT and
includes plans to identify and learn from agencies' experiences.
* The framework defines goals and strategies which are to be
implemented in three-phases.
HHS is in the initial phase of implementing the framework's strategies
but has not defined milestones for completion of this phase or later
phases.
In November 2004, HHS issued a request for information seeking public
input and ideas for developing a national health information network; a
task force of federal agencies is evaluating over 500 responses.
DOD and VA operate the largest health care delivery networks in the
nation, and their experiences in implementing EHRs offer important
lessons learned that could be applied to a national health records
system. These lessons include:
* Obtain full endorsement of top leadership:
* Define and adopt common standards and terminology:
* Recognize and address needs of the varied stakeholder communities:
* Deploy in small increments and build on success:
Other countries have begun initiatives to establish national health IT
infrastructures with government support and also provided valuable
lessons learned that can be applied to the U.S.'s efforts, such as:
* Focus on creating standards first;
* Establish a central organization to lead health IT efforts;
* Implement incrementally.
As a result of our review, we recommend that HHS establish plans and
milestones for fully implementing its framework for strategic action.
Background: IT in the Health Care Industry:
The President's Information Technology Advisory Committee[NOTE 2]
observed that, unlike most industries in which IT has improved
efficiency, quality, and productivity, health care still operates using
primarily paper-based records, phone calls, faxes, and mail.
* Unlike the nationalized health systems of many countries, the U.S.
health care system is composed of private, independent hospitals,
ambulatory care and long-term care facilities, and private individual
and group provider practices.
* The free market system does not inherently generate practical
mechanisms for sharing information critical to patient care.
According to HHS, health care is the largest sector of the economy that
has not fully embraced information technology.
Health IT is used to support health care quality and efficiency by
providing tools to improve patient care and to reduce administration
overhead. For example:
* Electronic health records (EHRs)[NOTE 3] provide patients and their
caregivers the necessary information required for optimal care while
reducing costs and administrative overhead, such as that associated
with patient registration, admission, discharge, and billing.
* Computer-assisted clinical decision support tools increase the
ability of health care providers to take advantage of current medical
knowledge from online medical references as they make treatment
decisions.
* Computerized provider order entry allows providers to electronically
order tests, medicine, and procedures for patients, reducing errors
associated with hand-written orders and prescriptions.
* Telehealth is used to provide health care to rural and remote areas
through the use of communications technologies.
NOTES:
[2] The President's Information Technology Advisory Committee's members
are appointed by the President to provide independent expert advice on
IT.
[3] There is a lack of consensus on what constitutes an EHR, and thus
multiple definitions and names exist for EHRs, depending on the
functions included. An EHR generally includes (1) a longitudinal
collection of electronic health information about the health of an
individual or the care provided, (2) immediate electronic access to
patient-and population-level information by authorized users, (3)
decision support to enhance the quality, safety, and efficiency of
patient care, and (4) support of efficient processes for health care
delivery.
Background: IT Adoption Rates in Health Care:
We recently reported that current health IT adoption rates in the
United States are varied and increasing the rates of IT adoption is
critical to achieving significant benefits.[NOTE4]
* Respondents to a recent survey conducted by the Medical Group
Management Association reported that only 31 percent of physician group
practices use fully operational EHRs.
* The Healthcare Information and Management Systems Society reported
that 19 percent of hospitals use fully operational EHRs.
* According to a study by the Commonwealth Fund, approximately 13
percent of solo physicians have adopted some form of EHR, while 57
percent of large group practices (50 or more physicians) have adopted
an EHR.
According to the Commonwealth Fund, gaps in adoption rates are further
widened by barriers and challenges to implementing health IT that are
greater for solo and small group practices.
NOTE:
[4] GAO, Health and Human Services' Estimate of Health Care Cost
Savings Resulting from the Use of Information Technology, GAO-05-309R
(Washington, D.C.: February 16, 2005).
Background: Challenges to Implementing IT:
While there are proven benefits to implementing health IT, the Medicare
Payment Advisory Commission[NOTE 5] identified other factors that
present financial, technical, and cultural challenges.
* Investment in IT can be costly and must compete with other
investments, and depends on the organization's ability to access
capital.
* Integrating new IT with other systems can further increase costs and
system maintenance requirements.
* Maintaining full operations when making system changes presents
additional challenges.
* Implementation of IT often requires changes in work processes and
culture.
* Physicians' reluctance is a major hurdle to implementing IT, and
overcoming it is key to successful projects.
NOTE:
[5] The Medicare Payment Advisory Commission is an independent federal
body established by the Balanced Budget Act of 1997 (P.L. 105-33) to
advise the U.S. Congress on issues affecting the Medicare program.
Background: Recent Studies on Cost and Benefits of Health IT:
Studies by the Center for Information Technology Leadership identified
savings from the widespread adoption of health IT.
* The Value of Healthcare Information Exchange and Interoperability
identified $78 billion in annual savings based on electronically
sharing health care data between providers and stakeholders, which
resulted in saving time and avoiding duplicate tests.
* The Value of Computerized Provider Order Entry in Ambulatory Settings
estimated $44 billion in annual savings based on avoidance of
unnecessary outpatient visits and hospital admissions, as well as more
cost-effective medication, radiology, and lab ordering.
The center and other health care experts acknowledge that these
estimates are based on limited data and a number of assumptions and,
therefore, are not necessarily complete and precise.
In October 2003, we reported significant financial benefits realized
from the implementation of health IT, including cost savings at VA and
expected savings at DOD (GAO-04-224; see appendix I).
Background: Administration's Health IT Agenda:
The President's health care IT plan calls for the widespread adoption
of interoperable EHRs within 10 years.
In April 2004, the President issued Executive Order 13335[NOTE 6] to
"provide leadership for the development and nationwide implementation
of an interoperable health information technology infrastructure to
improve the quality and efficiency of health care." Among other things,
the order called for:
* the appointment of a national coordinator for health IT who is to
report to the Secretary of HHS regarding progress on the development
and implementation of a strategic plan.
The Secretary appointed a national coordinator in May 2004 whose
responsibilities include coordination of programs and policies
regarding health IT across the federal government, and outreach and
consultation between the federal government and the private sector.
NOTE:
[6] Executive Order 13335, Incentives for the Use of Health Information
Technology and Establishing the Position of the National Health
Information Technology Coordinator (Washington, D.C.: April 27, 2004).
Background: HHS's Role in Health IT:
As a regulator, purchaser, health care provider, and sponsor of
research, HHS is taking steps to promote the use of IT in public and
private health care settings.
* The Agency for Healthcare Research and Quality (AHRQ) aims to
translate research findings into better patient care and provides
funding for state and regional IT demonstration projects and a national
resource center for grantees and organizations that are engaged in
health IT activities.
- According to HHS officials, over half of AHRQ's funding goes to rural
and small communities.
* The Centers for Medicare and Medicaid Services (CMS) administers the
Medicare program and works in partnership with states to administer the
Medicaid program and the States Children's Health Insurance Program;
CMS has established pilots to promote the adoption and effective use of
health IT in physicians' offices and to improve beneficiary telephone
customer service using web-based call centers.
Indian Health Service (IHS) provides health services to American
Indians and Alaskan Natives and reportedly uses a hospital information
system that provides order entry, results reporting, encounter
documentation, and other clinical functions.
The Health Resources and Services Administration (HRSA) aims to expand
access to high-quality health care and provide grants for community-
based activities in informatics, EHRs, and telehealth.
* HRSA awarded 65 grants and over $30 million for telehealth in 2004.
The National Institutes of Health (N I H) works to apply scientific
knowledge to extend healthy life and provide research grants for
computer technologies to facilitate access, storage, and use of
biomedical information, for training of informatics researchers and
developers, and access to informatics resources.
Background: Role of the National Committee on Vital and Health
Statistics:
The National Committee on Vital and Health Statistics (NCVHS) was
established in 1949 as a public advisory committee that is statutorily
authorized to advise the Secretary of HHS on health data, statistics,
and national health information policy, including the implementation of
health IT standards.
* The committee is responsible for developing recommendations to HHS
for standards to enable e-prescribing and delivered its first set of
recommendations to the department in September 2004 with additional
recommendations to be provided in March 2005.
* The committee is also responsible for making recommendations to the
Secretary of HHS for transaction and code set standards.
In November 2001, NCVHS called for federal leadership to accelerate and
coordinate progress on a national health information
infrastructure.[NOTE 7]
* NCVHS intends to continue to address issues related to health IT and
a national health information infrastructure and provide comments and
recommendations to the Secretary as appropriate.
NCVHS reviews results of HHS agencies' standards-setting initiatives,
along with government and nongovernmental requirements and issues, and
makes recommendations to the department secretary regarding the
adoption of health IT standards, as appropriate.
NOTE:
[7] NCVHS, Information for Health: A Strategy for Building the National
Health Information Infrastructure (Washington, D.C.: November 2001).
Background: DOD's Role in Health IT:
As previously reported,[NOTE 8] DOD has pursued the goal of providing
IT support to its hospitals and clinics since 1968.
* From 1976 to 1984, DOD spent about $222 million to acquire,
implement, and operate various health care computer systems.
* The Composite Health Care System (CHCS), deployed in 1993, is the
primary DOD medical information system now used in all military health
system facilities worldwide, supporting patient registration and
inpatient activity documentation, and providing laboratory, radiology,
pharmacy, drug interaction, and other functions.
NOTE:
[8] GAO, Information Technology. Greater Use of Best Practices Can
Reduce Risks in Acquiring Defense Health Care System, GAO-02-345
(Washington, D.C.: September 26, 2002).
DOD initiated CHCS II in 1997 as an advanced medical information system
to assist clinicians in making improved health care decisions and to
lower costs.
* As part of CHCS II, DOD is implementing a centralized Clinical Data
Repository of life-long health records for military health system
beneficiaries that provide documentation such as patient histories,
physician notes, and population health reporting.
* CHCS II represents DOD's EHR and will eventually replace the existing
CHCS.
According to HHS, DOD has a lengthy history working in remote and
medically underserved areas and has experience in using IT, such as
telehealth, to deliver care in isolated conditions which can be
compared with the conditions in some rural environments.
Background: VA's Role in Health IT:
VA is the country's largest health care provider and, according to
RAND,[NOTE 9] has been making significant strides in implementing
technologies and systems to improve care, including an EHR that allows
instant communication among providers across the country and reminds
providers of patients' clinical needs.
As we previously reported,[NOTE 10] VA has had an automated information
system in its medical facilities since 1985. In 1996, this system
evolved into the Veterans' Health Information Systems and Technology
Architecture (VistA), an integrated outpatient and inpatient system
that includes its EHR-the Computerized Patient Record System.
VA's EHR technologies are available for public use and are being
modified for transfer to rural and medically underserved settings.
NOTES:
[9] RAND, Improving Quality of Care: How the VA Outpaces Other Systems
in Delivering Patient Care (Santa Monica, CA: 2005).
[10] GAO Information Technology: Benefits Realized for Selected Health
Care Functions, GAO-04-224 (Washington, D.C.: October 22 31, 2003)
Background: Private Industry's Role in Health IT:
According to the National Coordinator for Health IT:
* While the federal government plays an important role in health IT
adoption, the effective use of health IT lies predominantly with the
private sector.
* The federal government can provide a vision and strategic direction
for a national interoperable health care system but will rely on the
private sector to provide a competitive technology industry, privately
operated support services, and shared investments in health IT
adoption.
* The private sector must develop the market institutions to deliver
the products and services that can transform the paper-based health
care system into an electronic, consumer-centered, and quality-based
system.
Background: Relevant Legislation:
Federal legislation requires specific activities related to the
implementation of health IT by both the public and private sectors.
* The Health Insurance Portability and Accountability Act (HIPAA) of
1996[NOTE 11] requires HHS to establish national standards for certain
financial and administrative electronic health care transactions and
national identifiers for providers, health plans, and employers.
* The Public Health Security and Bioterrorism Preparedness and Response
Act of 2002[NOTE 12] requires that the Secretary, in cooperation with
health care providers and state and local public health officials,
establish standards for interoperability of health alert and public
health surveillance networks between federal, state, and local public
health officials, and public and private health labs, hospitals and
other facilities.
Among other things, the Medicare Prescription Drug Improvement and
Modernization Act of 2003[NOTE 13] includes provisions for an
electronic prescription drug program and requires CMS to develop
standards for electronic prescribing.
* It also requires the establishment of a Commission on Systemic
Interoperability to provide a road map for interoperability standards.
* The act authorizes the Secretary of HHS to conduct a 3-year pay-for-
performance demonstration program under which physicians are to adopt
and use health IT to promote continuity of care, stabilize medical
conditions, prevent or minimize acute exacerbations of chronic
conditions, and reduce adverse health outcomes to meet beneficiaries'
needs.
NOTES:
[11] Public Law 104-191 (August 21, 1996).
[12] Public Law 107-188 (June 12, 2002).
[13] Public Law 108-173 (December 8, 2003).
Background: Previous GAO Reports on Health IT:
GAO has historically reviewed and reported issues related to the
federal government's efforts to implement health IT, including the need
for an implementation strategy, costs and benefits of health IT,
barriers to implementation, and DOD's and VA's efforts to implement
EHRs and exchange data.
Appendix I includes descriptions of GAO reports issued since 2000.
National Health IT Strategy: Office of the National Coordinator for
Health IT:
The mission of the Office of the National Coordinator for Health IT is
to develop and implement a strategic plan to guide the nationwide
implementation of interoperable health care IT in both the public and
private sectors.
* According to the national coordinator, the office is a transitional
organization with no permanent positions under the HHS Assistant
Secretary for Budget, Technology and Finance.
The first step in preparing a strategic plan was the release of a
framework for strategic action, and in accordance with Executive Order
13335, HHS released The Decade of Health Information Technology:
Delivering Consumer-centric and Information-rich Health Care (July
2004), which describes a framework for strategic action.
* The office intends to release a complete strategic plan during this
coming year to build upon the framework and provide detailed plans for
implementing the President's vision.
National Health IT Strategy: Framework for Strategic Action:
The framework for strategic action outlines an approach toward the
nationwide implementation of interoperable health IT in both the public
and the private sectors.
* It calls for a sustained set of actions which will be taken over many
years by the public and private health sectors.
* The framework outlines four major goals and 12 strategies for
implementing a strategy for national health IT.
The framework states a commitment to the development of
interoperability standards, a key component of progress in
interoperable health IT, and describes efforts to adopt standards for
use by all federal health agencies.
The framework also supports the role of the private sector and
recognizes that the adoption and effective use of health IT require a
joint effort between federal, state, and local governments and the
private sector.
As we testified in July 2004, as the national coordinator moves forward
with this framework, it will be essential to have continued leadership,
clear direction, measurable goals, and mechanisms to monitor progress.
[NOTE 14]
HHS's approach for implementing the framework's strategic actions
aggregates its goals and strategies into three phases.
* Phase I focuses on the development of market institutions to
stabilize the market, create a better environment for investment and
accountability, and lower the risk of health IT procurement.
* Phase II involves investment in clinical management tools and
capabilities such as EHRs, personal health records, telehealth, health
information exchange, and other mechanisms for high-performance care
delivery.
* Phase III supports the transition of the market to robust quality and
performance accountability, where clinicians have the tools and
capabilities to manage patients and populations and to deliver
consistently high-quality care in an efficient manner.
HHS is currently implementing phase I and, according to the national
coordinator, its initial efforts are focused on the building blocks of
EHR adoption, interoperability, and streamlined federal health
information systems.
* These building blocks are necessary to enable both the private and
public sectors to implement interoperable health information systems
and to provide a foundation for efforts in later phases, such as
personal health records and biosurveillance.
However, HHS has not established milestones for the completion of phase
I, nor has it defined or made plans for phases 11 and III.
According to officials with the Office of the National Coordinator for
Health IT, the office is in the process of establishing milestones for
the completion of phase I but has not made plans for phases II and III
because HHS has not formalized the organization or funding for future
activities.
Without defined milestones it remains unclear when the important
activities of phase I will be completed and when the building blocks to
support activities of the subsequent phases will be available.
The following slides describe the framework's 4 goals and 12 strategies
and key HHS IT initiatives that support the phase I goals.
NOTE:
[14] GAO, Health Care: National Strategy Needed to Accelerate the
Implementation of Information Technology, GAO-04-947T (Washington,
D.C.: July 14, 2004).
National Health IT Strategy: Framework for Strategic Action:
Goals:
Goal 1: Inform clinical practice with the use of EHRs;
Strategies[A]:
1. Incentivize EHR adoption;
2. Reduce risk of EHR investment;
3. Promote EHR diffusion in rural and underserved areas.
Goal 2: Interconnect clinicians so that they can exchange health
information using advanced and secure electronic communication;
Strategies[A]:
1. Foster regional collaborations;
2. Develop a national health information network;
3. Coordinate federal health information systems.
Goal 3: Personalize care with consumer-based health records and better
information for consumers:
Strategies[A]:
1. Encourage use of personal health records;
2. Enhance informed consumer choice ;
3. Promote use of telehealth systems.
Goal 4: Improve public health through advanced biosurveillance methods
and streamlined collection of data for quality measurement and
research:
Strategies[A]:
1. Unify public health surveillance architectures;
2. Streamline quality and health status monitoring;
3. Accelerate research and dissemination of evidence.
Source: GAO analysis of HHS information.
[A] Phase I strategies are shown in bold type.
[End of table]
National Health IT Strategy: Phase I: Standards for EHRs:
HHS is working with the private sector to develop standards for EHR
functionality, interoperability, and security in order to reduce the
risk of EHR implementation failure, a goal 1 strategy.
* In July 2004, three leading health care industry associations-the
Health Information and Management Systems Society, American Health
Information Management Association, and National Alliance for Health IT-
established a private sector task force to develop certification
requirements for ambulatory EHRs.
- The Certification Commission for Health IT is made up of private
sector and not-for-profit members with federal employees serving as
experts on the commission's work groups.
- The committee plans to define a basic certification process for EHRs
in ambulatory settings by summer 2005.
National Health IT Strategy: Phase I: HHS Support for Regional
Collaborations:
Currently, there are two HHS programs to support regional
collaborations through grants and contracts.
* In October 2004, AHRQ announced $139 million in multi-year grants and
contracts to promote the use of health IT, including five-year
contracts to five states to help them develop statewide networks.
* HRSA's Office for the Advancement of Telehealth provides seed money
and support to multi-stakeholder collaboratives within communities to
implement regional health information organizations. It provided $2.3
million in 2004.
These programs support the goal 2 strategy to foster regional
collaborations.
The Office of the National Coordinator for Health IT plans to host an
interoperability meeting with stakeholders this year to address
requirements for regional organizations and the national health
information network.
National Health IT Strategy: Phase I: National Health Information
Network:
In November 2004, HHS issued a request for information (RFI) for ideas
to develop a national health information network (NHIN)[NOTE 15]-a goal
2 strategy.
* The network is intended to provide technologies for the secure
movement of information used in the delivery of health care in the U.S.
integrated with public health surveillance and response, and shared
within the public domain.
* If implemented properly, the network should help achieve
interoperability of health IT used in the mainstream delivery of health
care in America, particularly pertaining to the information contained
in or used by EHRs.
* A key component of a NHIN is the development of interoperability
standards and policies for diffusion into practice.
The RFI addresses the goal to interconnect clinicians by seeking public
comment and input regarding how widespread interoperability of health
IT and health information exchange can be achieved.
The results of the RFI are intended to provide information for policy
discussions inside and outside the government about possible methods by
which widespread interoperability and health information exchange could
be deployed and operated on a sustainable basis.
* HHS intends to explore the role of the federal government in
facilitating deployment of a national health information network, how
it could be coordinated with efforts to define a federal health
architecture, and how it could be supported and coordinated by regional
health information organizations. [NOTE 16]
The RFI also requests input regarding privacy and security
considerations, including compliance with HIPAA rules and the role of
the private sector in the construction and implementation of a NHIN.
According to the national coordinator, HHS received over 500 responses
and has convened a governmentwide task force made up of over 100 people
from 17 agencies to review the responses and produce a summary.
NOTES:
[15] The national health information network is now referred to as the
nationwide health information network.
[16] Regional health information organizations are multi-stakeholder
collaboratives within communities that support health information
exchange efforts.
National Health IT Strategy: Phase I: Federal Health Information
Systems:
The office of the national coordinator is responsible for the Federal
Health Architecture (FHA) program which is to define a framework and
methodology for establishing the target architecture and standards for
interoperability and communication throughout the federal health
community, supporting a goal 2 strategy to coordinate federal health
information systems:
* FHA was initiated in 2003 in HHS's office of the chief information
officer and was incorporated into the national coordinator's office in
2004.
FHA is intended to provide a structure for bringing HHS's divisions and
other federal departments together through its partners' council, [NOTE
17] initially targeting standards for enabling interoperability.
* The FHA program is supported by four advisory work groups.
* Appendix II includes descriptions of the FHA work groups and their
responsibilities, followed by a table describing membership.
The FHA partners are responsible for improving coordination and
collaboration on federal health IT solutions and investments and
improving efficiency, standardization, reliability, and availability of
health comprehensive information solutions.
* According to the national coordinator, there is a strong need for the
federal government's health information systems to be able to exchange
data so that these systems become more efficient and cost-effective.
HHS plans to produce in September 2005 the first release of an
information architecture for the federal health enterprise to enable
collaboration and data sharing across the government and with various
organizations, such as states and private entities.
* The first release will contain foundational elements to support the
development and evolution of the full architecture which will occur
over several years.
The FHA's Consolidated Health Informatics (CHI) initiative is focused
on the adoption of health information interoperability standards,
identification of gaps and additional work areas in domains without
standards recommendations, and coordination with developers of health
information interoperability standards to promote accessibility and
distribution of adopted standards to support the FHA.
* Consolidated Health Informatics was initiated in December 2001 as an
OMB e-government project to establish federal health information
standards to enable federal agencies to build interoperable health data
systems.
* The project was incorporated into FHA in September 2004.
NOTE:
[17] The FHA partners' council includes almost 400 members from 15
agencies:
National Health IT Strategy: Phase I: Personal Health Records:
In January 2005, NCVHS held hearings on personal health records-a goal
3 strategy to personalize care-and identified issues, some specifically
related to the federal government.
* Issues discussed include privacy and information control, security of
health information, legal issues, cost, and interoperability.
* Federal issues include the relationship of roles in and uses of
personal health records to the larger health objectives of the federal
government, such as (1) what costs agencies will face, (2) how the
federal government should promote interoperability, and (3) whether
there needs to be a standardized approach to a personal health record
across all of the federal activities.
The hearings also discussed broader issues such as ownership and
control of personal health information and policy issues such as access
rights and authorization of usage.
National Health IT Strategy: Framework Support: Standards and
Interoperability:
According to the national coordinator, the development of technically
sound and robustly specified interoperability standards and policies is
a key component of progress toward the implementation of a national
strategy that provides interoperable health IT systems:
The development, approval, and adoption of standards for health IT is
an ongoing, long-term process that supports multiple goals of the
framework and includes federally mandated standards requirements (e.g.,
HIPAA) and a voluntary consensus process within a market-based health
care industry.
The use of some standards, such as those defined by HIPAA and MMA, is
mandated by the federal government while others are defined by
standards development organizations such as the American Association of
Medical Instrumentation and the National Council for Prescription Drug
Programs.
The following graphic provides an overview of the highly complex
standards-setting process for health care data exchange in the United
States.
Overview of the Process to Set Standards for the Exchange of Health
Care Data in the U.S.
[See PDF for image]
Note:
AAMI = American Association of Medical Instrumentation;
ASC = Accredited Standards Committee;
ASTM = American Society for Testing and Materials;
DICOM = Digital Imaging and Communication in Medicine;
HL7 = Health Level Seven;
IEEE = Institute for Electrical and Electronics Engineers;
NCPDP = National Council for Prescription Drug Programs;
NIST = National Institute of Standards and Technology, (part of the
Commerce Dept)
Source: Institute of Medicine, Patient Safety: Achieving a New Standard
for Care (Washington, D.C.: 2004).
[End of figure]
HHS identifies and researches standards that are defined by standards
development organizations and determines which approved standards are
appropriate for use in federal agencies' health IT systems.
According to an HHS official, the department has limited authority to
mandate standards outside of the federal government, but, through the
Consolidated Health Informatics initiative, is encouraging the
implementation of standards within the federal government to provide a
catalyst for the private sector to follow.
Federal agencies agreed to endorse 20 domains of health data standards
for information exchange as a model for the private sector, yielding 11
sets of standards to be used in federal IT architectures.
HHS is committed to supporting collaboration between the public and
private sectors to develop, adopt, and certify standards.
HHS divisions, such as AHRQ, CMS, NIH, CDC, and FDA, have been and
continue to be responsible for selecting and adopting standards and are
now included in the CHI initiative, supporting multiple goals of the
framework.
AHRQ and CMS are working on initiatives that support goal 1 of the
framework.
* AHRQ is working to identify and establish clinical standards and
research to help accelerate the adoption of interoperable health IT
systems, including:
- industry clinical messaging and terminology standards,
- national standard nomenclature for drugs and biological products, and
- standards related to clinical terminology.
CMS is responsible for identifying and adopting standards for e-
prescribing and for implementing the administrative simplification
provisions of HIPAA, including electronic transactions and code sets,
security, and identifiers.
NIH's work on standards supports the framework's goal 2.
* NIH's National Library of Medicine (NLM) is working on the
implementation of standard clinical vocabularies, including support for
and development of selected standard clinical vocabularies to enable
ongoing maintenance and free use within the United States' health
communities, both private and public.
- In 2003, NLM obtained a perpetual license for the Systematized
Nomenclature of Medicine (SNOMED)[NOTE 18] standard and ongoing
updates, making SNOMED available to U.S. users.
- Other efforts at NLM include the uniform distribution and mapping of
HIPAA code sets, standard vocabularies, and Health Level 7[NOTE 19]
code sets.
The Centers for Disease Control and Prevention (CDC), FDA, and NIH are
working on standards-setting initiatives that support the framework's
goal 4.
* CDC, through its Public Health Information Network (PHIN) initiative,
is working on the development of shared data models, data standards,
and controlled vocabularies for electronic laboratory reporting and
public health information exchange that are compatible with federal
standards activities such as CHI.
* FDA and NIH, together with the Clinical Data Interchange Standards
Consortium, a group of over 40 pharmaceutical companies and clinical
research organizations, have developed a standard for representing
observations made in clinical trials, the Study Data Tabulation Model.
In May 2003, we recommended to HHS that ongoing standards-setting
organizations coordinate their efforts to define and implement health
IT standards (GAO-03-139; see appendix I).
NOTES:
[18] SNOMED is a nomenclature classification for indexing medical
vocabulary, including signs, symptoms, diagnoses, and procedures. It
was adopted as a CHI standard in May 2004.
[19] HL7 is a standards development organization that creates message
format standards for electronic exchange of health information.
National Health IT Strategy: Framework's Goals and Supporting HHS IT
Initiatives:
In addition to those already described, other ongoing HHS IT
initiatives support the framework's goals.
The following table lists key HHS IT initiatives for health IT by
division and identifies the goals that they support.
Descriptions of each of the initiatives are included in appendix III.
National Health IT Strategy: Framework's Goals and Supporting HHS IT
Initiatives:
[See PDF for image]
Source: GAO analysis of HHS information.
[End of table]
National Health IT Strategy: Framework Support: Private Sector
Participation:
Certain private sector activities provide support for goals 1 and 2 of
the framework.
* The private sector task force, the Certification Commission for
Health IT, is working to develop certification procedures for EHRs,
supporting goal 1.
* The Commission on Systemic Interoperability, which includes
nationally recognized experts in the area of health IT, is charged by
the Medicare Modernization Act to develop a comprehensive strategy for
the adoption and implementation of health care IT interoperability
standards, which supports goal 2.
HHS has supported and continues to support opportunities for private
sector participation in establishing health care IT through grants and
funding for demonstration projects through its divisions.
HHS participates with the medical and public health communities,
academia, and health IT vendors through conferences and symposia.
* The national coordinator speaks at industry conferences that are
focused on identifying government incentives to encourage health IT
adoption in private industry.
* HHS's Secretarial Summit on Health IT held in July 2004 provided
nongovernmental participants opportunities to make recommendations
regarding incentives for health IT, population health, clinical
research, and health IT governance.
According to HHS, close collaboration between public and private
sectors can develop new methods for improving care without creating
unnecessary regulation and minimizing reporting burdens on private
industry.
Lessons Learned from VA and DOD:
DOD and VA experiences in implementing EHRs offer important lessons
learned that could be used in developing and implementing a national
health care effort. As providers and payers of health care services,
DOD and VA's lessons include:
* Obtain full endorsement of top leadership:
- Senior administrators and clinical leaders should share and
communicate a common sense of urgency regarding the need for change.
- Senior leadership's full endorsement, including support for funding,
is critical to successfully implementing an electronic health record,
promoting end-user support, and securing a usable product.
Implement an enterprise-wide communication plan:
* EHR implementation entails organizational change and acceptance
across the enterprise and at all organizational levels.
* System acceptance and support depend upon regular, effective
communication, from executive leadership levels down through end users.
* Keeping stakeholders informed of objectives, progress, problems
encountered and resolved, lessons learned, and benefits is critical to
setting realistic expectations and facilitating stakeholder buy-in.
Recognize and address needs of the varied stakeholder communities:
* A management/governance structure that represents the entire
stakeholder community should be established, and reflect clearly
defined roles, responsibilities, and decision-making authority among
the different levels of leadership.
* Users (i.e., clinicians, payers, and others) should have an early and
integral role in defining a strategy to meet their needs, establish
accountability for the initiative, and sustain long-term project
success.
* Users should be actively involved in all project phases, including
requirements definition, system design, development, testing, and
implementation.
Define and adopt common standards, terminology, and performance
measures:
* Early definition and adoption of common standards, terminology, and
performance measures (communication, data, and security) and agreement
on related implementation guidelines are essential to achieving data
quality and consistency, system interoperability, and information
protection.
Deploy in small increments and build on success:
* Follow an incremental system development approach to accommodate
evolving business processes, requirements, and technology changes;
limit initial deployment to a few test sites to allow time for the
process to mature, and assimilate lessons learned before full
deployment.
Customize training and support to sustain system implementation:
* Establish training programs that are tailored to meet the needs of
the varied users' groups. On-site clinical champions and subject-matter
experts should be identified and empowered to promote and demonstrate
the new system to other personnel and provide ongoing technical
assistance.
Lessons Learned from Other Countries:
Canada, Denmark, and New Zealand:
While the U.S. has just begun to develop a national strategy for health
IT adoption, Canada and Denmark have developed national strategies and
begun to take steps toward implementation, and New Zealand plans to
finalize its strategy in June 2005.
* Canada finalized its strategy in 2004 and is a year into
implementation.
* Denmark finalized its strategy in February 2003 and is 2 years into a
4-year implementation plan.
* New Zealand has prioritized six initiatives to be implemented in the
next 3 to 5 years.
These countries are farther along in their strategy development and
implementation than the U.S. and are able to share lessons learned from
their experiences.
Lessons Learned from Other Countries:
Overview of Canada's Health Care System:
The Canadian health care system supports publicly financed health for
over 31 million people.
The federal government is responsible for direct health service
delivery to veterans, native Canadians living on reserves, military
personnel, inmates of federal penitentiaries, and the Royal Canadian
Mounted Police, as well as health protection, disease prevention, and
health promotion services.
The administration and delivery of health care services is the
responsibility of each province or territory, guided by the provisions
of the Canada Health Act. The provinces and territories fund these
services with assistance from the federal government in the form of
fiscal transfers.
Canada Health InfoWay is working with the provinces and territories to
advance the IT building blocks needed for the health care system.
* Canada Health InfoWay is a corporation whose board of directors is
made up of representatives from all of the provinces and territories,
as well as elected representatives.
5
Lessons Learned from Other Countries:
Lessons Learned from Canada:
Lessons Learned:
Focus on creating standards first.
Recognize that creating a health IT infrastructure takes years, and
benefits may not be realized in the short term.
Identify a central visible point to provide political advocacy and
highlight the achievements of health IT as work progresses to help
maintain support for long-term projects.
Identify and provide appropriate incentives based on provincial and
territorial elements to motivate physicians to use IT.
Proactively resolve issues related to privacy protection.
Anticipate and mitigate border-crossing issues with implementing
telehealth, such as issues with licensing arrangements and cross-border
reimbursements.
Lessons Learned from Other Countries:
Overview of Denmark's Health Care System:
The Danish health care system serves a population of 5.3 million people
and is 85% tax-financed.
At the national level, the Ministry of Health is responsible for
legislation and preparing overall guidelines for the health care
sector, and the National Board of Health is responsible for supervising
health personnel.
The regional level consists of 14 counties and the Copenhagen Hospital
Corporation. The counties own and run hospitals and prenatal care
centers and finance general and specialist practitioners, pharmacies
and physiotherapists through the National Health Security System.
The responsibility for the municipal level includes nursing homes, home
nursing, health visitors, and school health services.
Denmark's National Strategy for IT in Health Care 2003 - 2007 was
finalized in February 2003.
* It states that the most important reasons for increasing the use of
IT in health care are related to the improvement of quality,
efficiency, and effectiveness of health care delivery.
* Three major initiatives of the National Strategy are:
- coordinated development, testing, and implementation of EHRs,
- a national database to organize health care terms and concepts, and:
- concept classifications to facilitate communications across sectors
and professions in health care.
Lessons Learned from Other Countries:
Lessons Learned from Denmark:
Lessons Learned:
Implementation of health IT across the entire country will take a long
time.
Involve health care service providers throughout the entire
implementation process.
A very strong central organization must lead the entire health IT
implementation from start to finish.
Integrate federal efforts with hospitals before undertaking a larger
national plan.
Anticipate and resolve funding, IT process reengineering, consensus-
building, and other issues during the planning phase to avoid negative
impacts on progress.
Realize that the investment in health care IT is costly, and short-term
gains are hard to identify.
Promote successes as soon as possible to encourage acceptance by
stakeholders.
Lessons Learned from Other Countries:
Overview of New Zealand's Health Care System:
The New Zealand health care system serves a population of 4 million
people.
At the national level, the Ministry of Health provides policy advice on
improving health outcomes and monitors the performance of the district
health boards.
The regional level consists of 21 district health boards. Each district
health board has up to 11 members, seven of which are elected by the
community and up to four of which are appointed by the Minister of
Health.
* District health boards are responsible for planning, funding and
ensuring the provision of health and disability services to a
geographically defined population.
New Zealand is currently redeveloping its health information strategy,
which is expected to be complete by June 2005.
The draft strategy identifies 12 action zones for implementation
planning over the next 3 to 5 years; six were selected as initial
priorities:
* Enable secure connections and access to health information:
* Ensure national systems anchors (such as the National Health Index)
are in place:
* Create and publish accessible key event summaries:
* Expand the level of electronic communication across primary and
secondary care:
* Extend the collection of health information:
* Safe Access to National Information within the context of the Health
Information Privacy Code is essential for the support of population
health:
Lessons Learned from Other Countries:
Lessons Learned from New Zealand:
Lessons Learned:
The distributed government model that governs New Zealand's health care
system works best.
High level EHR components that can be shared and accessed encourage
greater coordination of health services.
Provide adequate funding for and prioritize the initiatives:
Educate stakeholders about the value of developing health IT to
encourage stakeholder buy-in.
Lessons Learned from Other Countries:
Overview of the United Kingdom's Health Care System:
The United Kingdom's Department of Health is responsible for setting
health and social care policy in England; health services are largely
tax-financed in the United Kingdom and account for 14 per cent of
general government spending.
In summer 2002, the government set up the National Programme for IT
(NPfIT) which defines four main projects to be introduced in stages
across different regions:
* Electronic Patient Records;
* Electronic Appointment Booking;
* Electronic Transmission of Prescriptions;
* Communications Network:
NPfIT plans to have electronic booking substantially in place and to
have 50% of prescriptions transmitted electronically by the end of
2005.
We could not identify lessons learned from the United Kingdom's efforts
based upon publicly available information.
Conclusions:
Since establishing the Office of the National Coordinator for Health
IT, HHS has made progress toward coordinating federal health IT efforts
and reaching out to private industry.
However, coordination of standards development and adoption activities
throughout the health care industry, including federal efforts to
accelerate the process, remains a challenge.
HHS has not made long-term plans or established milestones for the
implementation of a national strategy to accelerate the adoption of IT
across the health care industry.
DOD's and VA's experiences in implementing EHR systems offer important
lessons learned that may be applied to HHS's efforts to help increase
the likelihood that interoperable EHRs could be available in the next
ten years.
The United States could benefit from other countries' experiences and
lessons learned from their efforts toward modernizing their health IT
infrastructures.
The National Coordinator for Health IT recognizes DOD's and VA's
efforts and works closely with them to share lessons learned from their
experiences with implementing health IT.
The national coordinator has recently initiated discussions with other
countries to also learn from their experiences in modernizing health
information infrastructures.
Recommendation:
To accelerate the adoption of interoperable IT for health care, we
recommend that the Secretary of HHS:
* establish detailed plans and milestones for each phase of the
framework for strategic action, and:
* take steps to ensure that plans are followed and milestones are met.
Agency Comments:
We requested comments from HHS, DOD, and VA on a draft of these
briefing slides.
* HHS did not provide comments.
* DOD's Chief Enterprise Architect for Military Health System provided
written technical comments, which we incorporated as appropriate.
* VA's Acting Deputy Chief Information Officer for Health provided oral
comments and agreed with the information presented.
Appendix I:
Recent GAO Reports on Health IT:
Health and Human Services' Estimate of Health Care Cost Savings
Resulting from the Use of Information Technology (GAO-05-309R; February
17, 2005): We reported that IT can improve the efficiency and quality
of medical care and result in costs savings and that, although
estimated nationwide savings are primarily based on studies with
methodological limitations and are contingent on much higher IT
adoption rates than are currently estimated, the potential for
substantial savings is promising.
Health Care: HHS's Efforts to Promote Health Information Technology and
Legal Barriers to its Adoption (GAO-04-991 R; August 13, 2004): We
identified major HHS IT initiatives and associated funding, and
reported that attempts by the federal government to address legal
issues that present barriers to the widespread use of IT have not been
sufficient.
Health Care: National Strategy Needed to Accelerate the Implementation
of Information Technology, (GAO-04-947T; July 14, 2004):
We reported that it will be essential to have continued leadership,
clear direction, measurable goals, and mechanisms to monitor progress
of the implementation of a national strategy for health IT.
Computer-Based Patient Records: VA and DOD Efforts to Exchange Health
Data Could Benefit from Improved Planning and Project Management, (GAO-
04-687; June 7, 2004): To help ensure progress in achieving the two-way
exchange of health information, we recommended that VA and DOD develop
an architecture for an electronic interface between their health
systems and establish a project management structure to guide the
initiative.
Computer-Based Patient Records: Improved Planning and Project
Management Are Critical to Achieving Two-Way VA-DOD Health Data
Exchange, (GAO-04-811 T; May 19, 2004):
We testified that DOD and VA were continuing with activities to support
the sharing of health data; nonetheless, achieving the two-way
electronic exchange of patient health information remained far from
being realized.
Computer-Based Patient Records: Sound Planning and Project Management
Are Needed to Achieve A Two-Way Exchange of VA and DOD Health Data (GAO-
04-402T; March 17, 2004): We testified that DOD and VA had made little
progress since November 2003 in determining an approach for achieving
two-way exchange of patient data and reported that DOD and VA have
taken measures towards implementing prior recommendations for enhancing
management and accountability.
Computer-Based Patient Records: Short-Term Progress Made But Much Work
Remains to Achieve A Two-Way Data Exchange Between VA and DOD Health
Systems (GAO-04-271 T; November 19, 2003): We testified that DOD and VA
faced challenges in exchanging standardized data and that a common
health information infrastructure and architecture was needed to
achieve data exchange capability.
Information Technology: Benefits Realized for Selected Health Care
Functions ( GAO-04-224, October 31, 2003): We reported significant
improvements in health care delivery and financial benefits realized
from the nation's health care community's implementation of health IT,
including cost savings resulting from VA's and DOD's implementation of
health IT.
Bioterrorism: Information Technology Strategy Could Strengthen Federal
Agencies' Abilities to Respond to Public Health Emergencies (GAO-03-
139; May 30, 2003):
We recommended that HHS coordinate with DHS, DOD, and VA to establish a
national IT strategy, and that ongoing standards-setting organizations
coordinate their efforts to define and implement health IT standards.
Computer Based Patient Records: Better Planning and Oversight by VA,
DOD, and IHS Would Enhance Health Data Sharing (GAO-01-459; April 30,
2001): We recommended that DOD, VA, and IHS create comprehensive and
coordinated plans to ensure that the agencies can share patient health
data, including performance measures and use of existing IT
capabilities.
Appendix II: Responsibilities of FHA Work Groups:
Food safety: recommend a target, business architecture to serve as the
framework for developing and implementing systems which support the
food safety business government-wide:
Interoperability: recommend target technical standards for
interoperability across the health line of business.
EHR: recommend a target, health care services electronic health record
business architecture, a component of the health lines of business, to
serve as framework within the federal sector for developing and
implementing an electronic health record.
Public health surveillance: recommend a target architecture related to
the health line of business to serve as the framework within the
federal sector for developing and implementing public health
surveillance systems.
Appendix II: FHA Work Groups' Members and Leaders:
[See PDF for image]
Source: HHS.
[End of table]
Appendix III: Descriptions of Key HHS IT Initiatives:
[See PDF for image]
Source: HHS divisions.
[End of table]
[End of slide presentation]
[End of section]
Appendix II: Comments from the Department of Health and Human Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES
Office of Inspector General:
Washington, D.C. 20201:
MAY 24 2005:
Mr. David A. Powner:
Director:
Information Technology Management Issues:
U.S. Government Accountability Office:
Washington, DC 20548:
Dear Mr. Powner:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO's) draft report entitled, "HEALTH
INFORMATION TECHNOLOGY-HHS is Taking Steps to Develop a National
Strategy" (GAO-05-628). The comments represent the tentative position
of the Department and are subject to reevaluation when the final
version of this report is received.
The Department provided several technical comments directly to your
staff.
The Department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Signed for:
Daniel R. Levinson:
Acting Inspector General:
Enclosure:
The Office of Inspector General (OIG) is transmitting the Department's
response to this draft report in our capacity as the Department's
designated focal point and coordinator for U.S. Government
Accountability Office reports. OIG has not conducted an independent
assessment of these comments and therefore expresses no opinion on
them.
COMMENTS BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES ON THE
U.S. GOVERNMENT ACCOUNTABILITY OFFICE'S REPORT ENTITLED "HEALTH
INFORMATION TECHNOLOGY--HHS IS TAKING STEPS TO DEVELOP A NATIONAL
STRATEGY" (GAO-05-628):
The Department of Health and Human Services (HHS) appreciates the
opportunity to review the draft General Accountability Office's (GAO)
report to the House of Representatives Committee on the Budget entitled
"HEALTH INFORMATION TECHNOLOGY - HHS is Taking Steps to Develop a
National Strategy." The focus of the GAO report is on HHS's recent
efforts to develop a National health IT strategy for realizing the
President's vision, lessons learned from the Department of Defense's
and Veterans Administration's and other countries' experiences in
implementing health IT.
The National Coordinator for Health Information Technology (National
Coordinator) was appointed on May 6, 2004, and heads the Office of the
National Coordinator for Health Information Technology (ONC). In a new
position in the Government with responsibilities for coordinating
internal Federal health information technology (health IT) programs as
well as coordinating with private sector health IT efforts, the
National Coordinator has taken an iterative approach to strategic
planning. This has allowed the National Coordinator to be inclusive in
planning, to balance near-term needs with long-term goals, and to work
within the constraints of available resources and appropriations. The
core of ONC's efforts are the Framework for Strategic Action (the
Framework) published in July 2004 and the Request for Information (RFI)
published in November 2004.
The GAO report highlights numerous other activities and developments
regarding health IT that have occurred during the past year as well,
including:
* ONC has consulted with, and actively partnered with, numerous Federal
agencies in the U.S. Government including the Departments of Veterans
Affairs, Defense, Commerce, and Homeland Security.
* ONC has met with many organizations and individuals representing
stakeholders of the healthcare system.
* ONC has reached out to States and regions through site visits and
town hall meetings to understand the health IT challenges experienced
at the local level as well as best practices for the use of, and
collaboration regarding, health IT.
* ONC has regularly testified before, and been informed by, the
National Committee on Vital and Health Statistics on issues critical to
the Nation's health IT goals.
* ONC has monitored and coordinated with the efforts of the Commission
for Systemic Interoperability.
* The National Coordinator has met with delegations involved with
health IT from other countries, including Canada, Netherlands, Japan,
Australia, Great Britain, and France.
As recommended in the GAO report, HHS agrees that detailed plans and
milestones are necessary, and they must meet near-term, medium-term,
and long-term planning needs. HHS has begun to take key steps to act on
the Framework and the lessons from the large public response to the
RFI.
The Secretary recently released his 500-Day Plan which includes as an
integral part the transformation of the health care system. This plan
includes long-term (5,000 day) visions and shorter-term (500 day)
strategies to achieve these visions. Three of those strategies include
health IT:
* Expressing a clear vision of health information technology that
conveys the benefits to patients, providers, and payers.
* Convening a national collaboration to further develop, set, and
certify health information technology standards and outcomes for
interoperability, privacy, and data exchange.
* Realizing the near-term benefits of health information technology in
the focused areas of adverse drug-incident reporting, e-prescribing,
lab and claims-sharing data, clinic registrations, and insurance forms.
Three of the Secretary's longer-term visions are:
* Nearly all health records can be linked through an interoperable
system that protects privacy as it connects patients, providers, and
payers - resulting in fewer medical mistakes, less hassle, lower costs,
and better health.
* Consumers are better informed and have more choices.
* Payers reward providers for healthy outcomes rather than quantity of
care and services.
HHS funds have been reallocated to provide a total of $32.8 million to
initiate this work in fiscal year (FY) 2005. For FY 2006, the President
has requested an additional $125 million which, if approved, will help
HHS to further develop milestones and plans that are consistent with
the 500-Day Plan.
In May 2005, the Secretary released the Health IT Leadership Panel
Report, prepared by the Lewin Group, an HHS contractor, which
highlighted findings from a small group of Fortune 100 CEOs who
convened to consider and discuss issues related to health IT. This
report called for Government to be a leader, catalyst, and convener of
the Nation's health information technology effort. The Secretary has
already begun by listening to stakeholders through a series of
roundtable discussions.
HHS will continue working in concert with those principles and items
identified by GAO as lessons from the VA and DOD. This includes the
continued leadership of the Secretary as evidenced in his 500-Day Plan;
identification and adoption of additional clinical standards through
Federal Health Architecture and Consumer Health Information as well as
e-prescribing standards under the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003; additional stakeholder
input through collaboration; and, focus on near-term wins to "deploy in
small increments and build on success."
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
THE DEPUTY SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:
May 20, 2005:
Ms. Linda D. Koontz:
Mr. David A. Powner:
U. S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Ms. Koontz and Mr. Powner:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, HEALTH INFORMATION
TECHNOLOGY: HHS is Taking Steps To Develop a National Strategy (GAO-05-
628). VA is pleased that this review found the lessons learned from VA
and the Department of Defense could provide Health and Human Services
valuable insights as it develops a national health information
technology infrastructure. Technical comments are included in the
enclosure.
VA appreciates the opportunity to comment on your draft report.
Sincerely yours,
Signed for:
Gordon H. Mansfield:
Enclosure:
[End of section]
(310475):
FOOTNOTES
[1] According to HHS, market institutions include certification
organizations, group purchasing entities, and low-cost implementation
support organizations that do not currently exist but are necessary to
support clinicians as they procure and use IT.
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