![](media/image1.png){width="2.1354166666666665in"
height="1.2916666666666667in"}

The ONC-Coordinated

Federal Health IT Strategic Plan:

2008-2012

June 3, 2008

[]{.mark}

[]{.mark}

**Table of Contents**

Executive Summary iii

Strategic Plan Overview 1

Tabular Summary of Plan 8

Goal 1: Patient-focused Health Care 11

> Objective 1.1: Privacy and Security for Health Care 11
>
> Objective 1.2: Interoperability for Health Care 14
>
> Objective 1.3: Adoption for Health Care 19
>
> Objective 1.4: Collaborative Governance for Health Care 23

Goal 2: Population Health 27

> Objective 2.1: Privacy and Security for Population Health 27
>
> Objective 2.2: Interoperability for Population Health 30
>
> Objective 2.3: Adoption for Population Health 34
>
> Objective 2.4: Collaborative Governance for Population Health 36

Appendix A: Strategies, Milestones, and Action Items A1

Appendix B: Matrix of Federal Health IT Initiatives A25

Appendix C: Initiative Descriptions and Progress Summaries A30

Appendix D: Current ONC Budget and Strategic Plan Objectives A68

Appendix E: Acronym List A70

> **Acknowledgements**
>
> The Office of the National Coordinator is deeply grateful to the
> leaders and key staff from each federal agency involved with the
> development of this document.
>
> Development of this plan was supported under contract GS10F0223P by
> professional staff from Avalere Health LLC.  The Office of the
> National Coordinator gratefully acknowledges Avalere's important
> contributions to the conceptualization of the plan, as well as to the
> assembly and expression of the ideas of persons across the government.

**Executive Summary**

On April 27, 2004, President Bush issued Executive Order (EO) 13335 "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." EO 13335 established the
position of a National Coordinator for Health Information Technology
(IT) within the Office of the Secretary of Health and Human Services. 
The National Coordinator was charged with coordinating federal health IT
policies and programs and relevant executive branch agency outreach and
consultation with public and private entities.  As such, the National
Coordinator provides the day-to-day leadership necessary for the
development of a health IT infrastructure for the nation.

EO 13335 also charged the National Coordinator with developing,
maintaining, and directing

" ... the 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 reduce medical
errors, improve quality, and produce greater value for health care
expenditures."

Accordingly, the Office of the National Coordinator for Health
Information Technology (ONC) has worked across the federal government to
develop this ONC-coordinated Federal Health IT Strategic Plan (the
Plan), which identifies the federal activities necessary to achieve the
nationwide implementation of this technology infrastructure throughout
both the public and private sectors.  The timeframe of the Plan is
2008-2012.

The Plan has two goals, Patient-focused Health Care and Population
Health, with four objectives under each goal. The themes of privacy and
security, interoperability, IT adoption, and collaborative governance
recur across the goals, but they apply in very different ways to health
care and population health.

Goal 1) *Patient-focused health care:* Enable the transformation to
higher quality, more cost-efficient, patient-focused health care through
electronic health information access and use by care providers, and by
patients and their designees.

> *Objective 1.1 -- Privacy and Security:* Facilitate electronic
> exchange, access, and use of electronic health information while
> protecting the privacy and security of patients' health information
>
> *Objective 1.2 --* *Interoperability:* Enable the movement of
> electronic health information to where and when it is needed to
> support individual health and care needs
>
> *Objective 1.3 -- Adoption:* Promote nationwide deployment of
> electronic health records and personal health records that put
> information to use in support of health and care
>
> *Objective 1.4 -- Collaborative Governance:* Establish mechanisms for
> multi-stakeholder priority-setting and decision-making to guide
> development of the nation's health IT infrastructure

Goal 2) *Population health:* Enable the appropriate, authorized, and
timely access and use of electronic health information to benefit public
health, biomedical research, quality improvement, and emergency
preparedness.

> *Objective 2.1 -- Privacy and Security:* Advance privacy and security
> policies, principles, procedures, and protections for information
> access and use in population health
>
> *Objective 2.2 -- Interoperability:* Enable the mobility of health
> information to support population-oriented uses
>
> Objective 2.3 -- *Adoption:* Promote nationwide adoption of
> technologies and technical functions that will improve population and
> individual health
>
> Objective 2.4 -- *Collaborative Governance:* Establish coordinated
> organizational processes supporting information use for population
> health

Achievement of the eight objectives is tied to measurable outcomes.

The Plan articulates 43 strategies that describe the work needed to
achieve each objective.  Each strategy is associated with a milestone
against which progress can be assessed, and a set of illustrative
actions to implement each strategy. As a group, the strategies are
characterized by:

-   Commitment to the engagement of multiple stakeholders across the
    public and private sectors;

-   Concern for reliability, confidentiality, privacy, and security when
    exchanging, storing, and using electronic health information; and

-   Focus on the consumer of health care as a critical participant in
    achieving the two overarching goals of the Strategic Plan, as
    described above.

The goals, objectives, and strategies of the Plan portray the totality
of what must be done, in a coordinated manner distributed across the
federal government, to achieve an interoperable health IT infrastructure
for the nation in support of patient-focused health care and population
health.  To emphasize the collaborative nature of this initiative, a
major component of the Plan is a compilation of relevant federal agency
projects, as well as partnerships between those federal agencies and
other stakeholders, that are already underway in pursuit of one or more
of the specific objectives.

Consistent with ONC's mission and role, the Plan is not limited to the
activities and tasks that ONC directly sponsors.  This Plan is primarily
federally focused with many of the strategies proposed in the Plan
designed to harmonize activities in the public and private sectors. This
approach is designed to ensure that federal resources allocated to
health IT, while supporting the individual and distinct missions of the
Departments, are also positioned to realize maximum benefit for the
nation as a whole.

In developing the Plan, ONC worked with other federal agencies to
solicit input and assure that the full breadth of federal activity was
reflected.  ONC will periodically update the Plan and actively engage
other federal agencies in re-evaluating the strategic objectives and
strategies, and in tracking progress toward these goals and objectives. 

**[Strategic Plan Overview]{.underline}**

**Background, Mission and Vision**

On April 27, 2004, President Bush issued Executive Order (EO) 13335 "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," establishing the position of
a National Coordinator for Health Information Technology (IT) within the
Office of the Secretary of Health and Human Services. Acknowledging the
role of multiple executive branch agencies in addressing the vision of
this nationwide infrastructure, the National Coordinator was charged
with ensuring coordination of federal health IT policies and programs
and of relevant executive branch agency outreach and consultation with
public and private entities. Thus, the National Coordinator provides the
leadership necessary to support national progression to a health IT
infrastructure envisioned to:

-   Ensure that appropriate information to guide medical decisions is
    available at the time and place of care;

-   Improve health care quality, reduce medical errors, and advance the
    delivery of appropriate, evidence-based medical care;

-   Reduce health care costs resulting from inefficiency, medical
    errors, inappropriate care, and incomplete information;

-   Promote a more effective marketplace, greater competition, and
    increased choice through the wider availability of accurate
    information on health care costs, quality, and outcomes;

-   Improve the coordination of care and information among hospitals,
    laboratories, physician offices, and other ambulatory care providers
    through an effective infrastructure for the secure and authorized
    exchange of health care information; and

-   Ensure that patients' individually identifiable health information
    is secure, protected, and available to the patient to be used for
    medical and non-medical purposes, as directed by the patient, as
    appropriate.

Upon publication of EO 13335, President Bush also set an ambitious
target for the majority of Americans to have access to electronic health
records (EHRs) by 2014.

**A Coordinated and Collaborative Effort**

EO 13335 also charged the National Coordinator with developing,
maintaining, and directing

" ... the 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 reduce medical
errors, improve quality, and produce greater value for health care
expenditures." The Office of the National Coordinator for Health
Information Technology (ONC) has worked with multiple federal agencies
to develop this Strategic Plan, which identifies the federal activities
necessary to achieve the nationwide implementation of this technology
infrastructure throughout both the public and private sectors.

This plan explicitly recognizes that the federal government has a
profound role in promoting interoperable health IT -- not as an end in
itself, but because of the existing federal responsibilities for both
the individual health care costs of federal and private beneficiaries
and the vast majority of the population health activities and the
provision of federal disability benefits in the nation. Because so much
of the information necessary to improve population health can be drawn
from the clinical information generated in the course of direct health
care delivery, there would be considerable duplication of effort and
waste of federal resources if two separate health IT infrastructures
were implemented. Thus, this Strategic Plan includes goals for a
nationwide health IT infrastructure that is designed to meet the needs
of patient-focused health care, population health, and use by the
patient. The federal government will receive substantial benefit from
the efficiencies that result from federal activities to attain such an
infrastructure. Moreover, the health of the nation is a public good in
which the federal government has intense interest. This Plan organizes
and details a coherent set of goals, objectives, and strategies
comprising the nation's health IT agenda. The Plan describes federal
activities that are currently underway and address these goals and
objectives. Some of these are conducted by ONC. Most are conducted by a
broad array of federal agencies and departments, with ONC as one central
collaboration and coordinating body amongst these agencies to ensure
that they have the opportunity to leverage each others' activities, and
that such activities work in harmony. The objectives included in this
Plan create an outline for organizing current and future federal
initiatives to complement each other and act synergistically to achieve
each objective.

The federal government is one of several audiences for this Plan. Given
the nationwide reach of the goals and the breadth of resources needed to
achieve them, the broader intended audience for this document
specifically includes public and private providers of health care,
consumers or recipients of health care, the health IT industry, consumer
advocates, and population health information users. The Plan outlines,
for this full range of stakeholders, how the nation can realize a set of
widely endorsed goals and how these stakeholders can become active
participants in achieving the vision. It demonstrates how health IT
activities in the public sector align with and benefit from activities
in the private sector, and vice versa, putting each sector's resources
to best use.

**Overview of the Federal Health IT Strategic Plan**

This federal Strategic Plan has two main goals: 1) transforming care
delivery, personal health, and support through the access to and use of
electronic health information; and, 2) advancing population health
(public health, biomedical research that makes use of health care
information, health care quality improvement, and emergency
preparedness) through timely access to and use of electronic health
information. Underpinning the approach to these goals is a commitment to
a public-private, multi-stakeholder approach and a concern for
reliability, confidentiality, privacy, and security when exchanging,
storing, and using electronic health information.

[Goal One: Patient-focused Health Care]{.underline} -- supports and
builds on EO 13335 by seeking to enable high-quality and efficient
patient-focused health care through the use of electronic health
information by providers, as well as patients and their designees. The
information generated and exchanged through an interoperable
infrastructure, with appropriate available tools, will enable health
care providers to:

-   Better coordinate and personalize care by providing other health
    care providers access to comprehensive and longitudinal medical
    records, and providing individuals access to their own records
    through personal health records;

-   Reduce medical errors;

-   Support the prevention of illness; and

-   Minimize duplicative treatments and tests.

Additionally, individuals will benefit from improved system-wide
efficiencies through decreased paperwork, consistent and controlled
access to health information, and the ability to securely access and
transfer their information for purposes that may extend beyond health
care.

[Goal Two: Population Health]{.underline} -- supports the use of
electronic health information---primarily, but not exclusively,
generated as a by-product of health care delivery---for critical
national needs relating to public health, biomedical research, quality
improvement, and emergency preparedness. Such use would promote early
and effective management of infectious disease outbreaks, improved
tracking of chronic disease management, the ability to gather data for
research purposes, and the evaluation of health care based on value, by
way of comparable price and quality information.

The consumer of health care is a critical participant in achieving both
goals, as the consumer is at the center of information exchange in
support of health care delivery, and a beneficiary of improved
population health capabilities and other key activities. In several
places, this Plan anticipates the emergence of technologies, generally
referred to as "personal health records" or PHRs. These tools support
consumers' (or their designees') abilities to manage, access, and share
their own health information, much of which is generated by care
providers.

The Plan for achieving each goal is detailed through objectives,
strategies, and illustrative actions that align with a set of four core
functional components: 1) policies relating to privacy and security; 2)
standards, networking, and interoperability; 3) adoption of technology
and information use; and 4) collaborative governance and
decision-making. These components are necessary to create an environment
in which health information can be exchanged securely and accessed in a
timely manner for the purpose of patient care and population health.

> *1. Policies Relating to Privacy and Security ("Privacy and
> Security")*
>
> The success of a nationwide, interoperable health IT infrastructure in
> the United States will require a high degree of public confidence and
> trust. Careful attention is needed both to ensure the functional
> capabilities to exchange health information, and to maintain privacy
> and security. Only by engaging all stakeholders, particularly
> consumers, in a coordinated effort can health information be protected
> in a manner that promotes public trust.
>
> *2. Standards, Networking, and Interoperability ("Interoperability")*
>
> To advance high-quality, safe and efficient health care and promote
> population health, information must be readily exchanged among diverse
> participants. To effectively exchange health information, health IT
> systems and products must use consistent, specific data and technical
> standards. These harmonized data and technical standards must be
> agreed upon and in some instances required. They must be testable in,
> and applicable to, different systems, types of information, and health
> care settings.
>
> *3. Adoption of Technology and Information Use ("Adoption")*
>
> To transform health care and population health services, relevant
> health information users must adopt interoperable technologies. To
> this end, it is necessary to identify and reduce or remove the many
> existing obstacles to adoption of EHRs in health care settings.
> Initiatives such as the Centers for Medicare & Medicaid Services (CMS)
> Electronic Health Record Demonstration, described later in this
> document, should help advance the adoption agenda. There must be
> sufficient numbers of trained technical staff within health care and
> population health systems to enable development and deployment of
> useful technologies. It is also necessary to support adoption of PHRs,
> and other direct consumer uses of health IT and networking. As
> barriers are identified and addressed, the current slow rate of
> adoption will be followed by a period of rapid uptake, as the beliefs
> of providers, payers, and consumers shift from "why do we need it?" to
> "we cannot do without it". Adoption efforts must ensure that the
> benefits of health IT reach disadvantaged and underserved populations,
> and do not widen the often-cited "digital divide".
>
> *4. Collaborative Governance and Decision-Making ("Collaborative
> Governance")*
>
> Progress toward a nationwide, secure, interoperable health IT
> infrastructure and the Presidential target for the majority of
> Americans having access to electronic health records (EHRs) by 2014
> requires support and participation from all health care stakeholders
> and their participation in advancing health IT. The necessary
> planning, consensus building, priority-setting, and consistent
> approaches to implementing policies can best be achieved through
> appropriate structures and mechanisms for collaborative governance. It
> is essential that such governance occurs across the public and private
> sectors and involves all individuals and organizations with a stake in
> health-related activities.

Each of the core functional components of the Plan requires the support
of the other components in order to be fully successful. For example,
interoperability requires the public trust that derives from privacy and
security protections. The incentives that will drive adoption of health
IT require the support of all stakeholders that will stem from
collaborative governance.

**Interwoven (Matrix) Structure of the Plan**

Under each of the Plan's two goals, there are four objectives: one
addressing privacy and security, one addressing interoperability, one
addressing adoption, and one addressing collaborative governance. In
this way, and as shown in the table below, the Plan takes on a matrix
structure. Attainment of all eight objectives of this Plan will be
required to establish and derive maximum value from a sustainable,
secure, interoperable health IT infrastructure for the nation, and thus
achieve the vision of EO 13335.

+-------------+-------------+-------------+-------------+-------------+
|             | **Privacy   | **Interop   | *           | **Co        |
|             | and         | erability** | *Adoption** | llaborative |
|             | Security**  |             |             | G           |
|             |             |             |             | overnance** |
+-------------+-------------+-------------+-------------+-------------+
| **Goal 1.   | **Objective | **Objective | **Objective | **Objective |
| Pati        | 1.1:**      | 1.2:**      | 1.3:**      | 1.4:**      |
| ent-Focused |             |             |             |             |
| Health      | Facilitate  | Enable the  | Promote     | Establish   |
| Care**      | electronic  | movement of | nationwide  | mechanisms  |
|             | exchange,   | electronic  | deployment  | for         |
|             | access, and | health      | of EHRs and | multi-      |
|             | use of      | information | PHRs and    | stakeholder |
|             | electronic  | to support  | other       | prior       |
|             | health      | patients'   | consumer    | ity-setting |
|             | i           | health and  | health IT   | and         |
|             | nformation, | care needs  | tools       | deci        |
|             | while       |             |             | sion-making |
|             | protecting  |             |             |             |
|             | the privacy |             |             |             |
|             | and         |             |             |             |
|             | security of |             |             |             |
|             | patients'   |             |             |             |
|             | health      |             |             |             |
|             | information |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Goal 2.   | **Objective | **Objective | **Objective | **Objective |
| Population  | 2.1:**      | 2.2:**      | 2.3:**      | 2.4:**      |
| Health**    |             | Enable      |             | Establish   |
|             | Advance     | exchange of | Promote     | coordinated |
|             | privacy and | health      | nationwide  | org         |
|             | security    | information | adoption of | anizational |
|             | policies,   | to support  | t           | processes   |
|             | principles, | populati    | echnologies | supporting  |
|             | procedures, | on-oriented | to improve  | information |
|             | and         | uses        | population  | use for     |
|             | protections |             | and         | population  |
|             | for         |             | individual  | health      |
|             | information |             | health      |             |
|             | access in   |             |             |             |
|             | population  |             |             |             |
|             | health      |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

**Objectives and Strategies**

In this document, the plan for achieving each goal is detailed through
four objectives and multiple strategies to address each objective. To
assess progress, each objective is accompanied by one or more measurable
outcomes. For some of the objectives---for example, those related to
deployment of the National Health Information Network---the measures are
labeled as "developmental". In these cases, the initiatives to execute
the objectives have not yet matured and instruments to measure progress
do not yet exist. The targets for these developmental measures will be
developed after the baseline studies are conducted. The Plan indicates,
where possible, when baseline data are expected for the developmental
measures. As in any coordinated effort to achieve strategic goals, the
strategies are designed to be mutually reinforcing and will, by
necessity, overlap to some extent. Interconnections among strategies
that address different goals and objectives are intentional.

The main body of the Plan includes a synopsis of each strategy. Appendix
A contains more detailed descriptions of each strategy, along with
milestones and the targeted time at which each milestone is expected to
be achieved. For each strategy, Appendix A includes component actions
that are more specific tasks to be undertaken in pursuit of each
milestone. Since this document is a strategic plan, the actions are
provided as "illustrative" examples and *do not represent a
comprehensive list of the action steps* that would need to occur, by ONC
or by other federal offices or entities. In many cases, the action steps
reflect federal agency activities currently underway. All such action
items should be considered subject to change as they undergo review and
evaluation.

The goals, objectives, and strategies of this Plan seek to portray the
totality of what must be done, in a coordinated manner distributed
across the federal government, to accomplish the health IT agenda and
thus realize the vision of the EO 13335. Because the strategies of the
Plan coordinate actions across the federal government, many of the
strategies are interdependent.

**Related Initiatives and Progress to Date**

To characterize the collaborative nature of this initiative, relevant
federal agency projects, as well as partnerships among those federal
agencies and other stakeholders, are cited under the specific
objective(s) they address. These activities were either ongoing at the
time of, or began after, the signing of EO 13335 in 2004. As new federal
activities are developed or initiated, we will periodically update the
Strategic Plan to include them.

The appendices provide further explanation of the initiatives cited in
this Plan. Appendix B contains a matrix that portrays how these
initiatives support the goals and objectives of the Plan, while Appendix
C provides a summary for each of the initiatives.

**Timeframe**

The timeframe for the Plan is five years (FY 2008-2012), so the target
dates for all outcomes and milestones are 2012 or earlier. While the
President's 2014 target (mentioned earlier) is technically outside the
time span of this five-year Strategic Plan, that target date shapes the
timelines for the Plan's objectives and strategies.

**Scope of this Strategic Plan**

Consistent with ONC's mission and role, the Plan is not limited to the
activities and tasks that ONC directly sponsors. (Appendix C describes
the activities supported by ONC's FY 2008 and estimated FY 2009
budgets.) The Plan is designed to build upon, leverage, and coordinate
the existing and critical roles that many federal, state, local, tribal,
and private stakeholders already play in advancing these goals. Many of
the strategies proposed in this Plan are designed to harmonize
activities in the public and private sectors, to ensure that federal
resources allocated to health IT realize maximum benefit for the nation
as a whole.

The Plan is also designed to achieve interoperability over time without
requiring either substantial replacement of existing health IT solutions
or the use by all stakeholders of a single health IT system, thus
avoiding the necessity for a large increase in funding for those federal
or non-federal entities that already have robust health IT solutions in
place. Rather, the Plan proposes to set up the foundation and
infrastructure to support interoperable technologies and automated
exchange of health information, in support of the nation's health care
system.

This Plan acknowledges that health care is provided by a wide range of
professionals, and all health professionals are envisioned as users of
health IT. The term "health professional" is explicitly meant to include
physicians, nurses, and other health professional groups, including
health information management professionals, whose coordinated efforts
are essential to an effective and efficient health care system.

This Plan focuses primarily on information collected for purposes of
health care delivery and population health, and also contemplates other
uses of that information for administrative purposes, including
disability determinations. Where and when data elements are useable for
purposes beyond care delivery and population health (as is the case with
diagnostic or procedural codes), the standards activities integral to
this Plan will be coordinated with existing standards that have been
identified through the activities related to the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). In those instances
where health-related data support financial and administrative
activities, the benefits of interoperability described in this Plan will
also accrue to these components of the health care system.

The Plan includes, as a component of Goal Two, facilitation of research
that makes use of data collected from or about individuals in
conjunction with patient-focused health care. Some types of clinical,
translational, and health services research therefore fall within the
scope of the Plan. Basic research and animal studies are excluded.

Ultimate achievement of the Plan's goals will require a robust
biomedical informatics, public health informatics, and health services
research enterprise. Such research will be required to address known
challenges (such as knowledge management, natural language processing,
and the association of health IT with health outcomes) and also respond
to new challenges that arise as a result of more widespread deployment
of health IT and growing use of health care information in population
health. The Plan assumes that such research will continue, but does not
include it.

Lastly, this Plan does not propose new policies. The use of new
technologies will raise the need for new policies, and this Plan
describes specific activities where new policies need to be considered
and options evaluated, but does not directly propose them.

**Future Steps**

In developing this Plan, ONC worked with other federal agencies to
solicit input and assure that the full breadth of federal activity was
reflected.  ONC will periodically update this Plan and actively engage
other federal agencies in re-evaluating the strategic objectives and
strategies, and in tracking progress toward these goals and objectives. 

Reflecting the responsibilities assigned to the National Coordinator,
ONC will serve as the coordinator with federal agencies and departments
to ensure the timely implementation of the strategies and actions by
individual agencies - aligned with their respective mission-specific
priorities - that are consistent with or complement this Plan\'s eight
objectives. As a first step, ONC will work with the agencies and
departments specifically referenced in this Plan, and others as new
opportunities emerge, to delineate which organization(s) are primarily
responsible for implementation of each milestone.

**Tabular Summary of Plan**

The following pages offer a table that summarizes the Plan, with highly
abbreviated "shorthand" statements of the objectives, outcome measures
for each objective, strategies, and milestones as well as the target
date(s) for each listed milestone. Due to space constraints, the
"shorthand" statements might not reflect the entire scope of the
strategy or outcome covered by the complete statement in the Plan. This
table is intended to serve as an overview of the Plan's structure and a
quick reference guide to its components.

+----------+------------------+------------------------+---+---+---+---+---+
| **Goal   |                  |                        |   |   |   |   |   |
| 1:       |                  |                        |   |   |   |   |   |
| Patient  |                  |                        |   |   |   |   |   |
| -focused |                  |                        |   |   |   |   |   |
| Health   |                  |                        |   |   |   |   |   |
| Care**   |                  |                        |   |   |   |   |   |
|          |                  |                        |   |   |   |   |   |
| **Enable |                  |                        |   |   |   |   |   |
| the      |                  |                        |   |   |   |   |   |
| transf   |                  |                        |   |   |   |   |   |
| ormation |                  |                        |   |   |   |   |   |
| to       |                  |                        |   |   |   |   |   |
| higher   |                  |                        |   |   |   |   |   |
| quality, |                  |                        |   |   |   |   |   |
| more     |                  |                        |   |   |   |   |   |
| ef       |                  |                        |   |   |   |   |   |
| ficient, |                  |                        |   |   |   |   |   |
| patient  |                  |                        |   |   |   |   |   |
| -focused |                  |                        |   |   |   |   |   |
| health   |                  |                        |   |   |   |   |   |
| care     |                  |                        |   |   |   |   |   |
| through  |                  |                        |   |   |   |   |   |
| el       |                  |                        |   |   |   |   |   |
| ectronic |                  |                        |   |   |   |   |   |
| health   |                  |                        |   |   |   |   |   |
| inf      |                  |                        |   |   |   |   |   |
| ormation |                  |                        |   |   |   |   |   |
| access   |                  |                        |   |   |   |   |   |
| and use  |                  |                        |   |   |   |   |   |
| by care  |                  |                        |   |   |   |   |   |
| p        |                  |                        |   |   |   |   |   |
| roviders |                  |                        |   |   |   |   |   |
| and by   |                  |                        |   |   |   |   |   |
| patients |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| their    |                  |                        |   |   |   |   |   |
| des      |                  |                        |   |   |   |   |   |
| ignees** |                  |                        |   |   |   |   |   |
+==========+==================+========================+===+===+===+===+===+
| **Obj    | **Strategy**     | **Milestone**          | * | * | * | * | * |
| ective** |                  |                        | * | * | * | * | * |
|          |                  |                        | 2 | 2 | 2 | 2 | 2 |
|          |                  |                        | 0 | 0 | 0 | 0 | 0 |
|          |                  |                        | 0 | 0 | 1 | 1 | 1 |
|          |                  |                        | 8 | 9 | 0 | 1 | 2 |
|          |                  |                        | * | * | * | * | * |
|          |                  |                        | * | * | * | * | * |
+----------+------------------+------------------------+---+---+---+---+---+
| **1.1 -  | 1.1.1: Develop a | Publication of         |   |   |   |   |   |
| Privacy  | confidentiality, | framework.             |   |   |   |   |   |
| and      | privacy, and     |                        |   |   |   |   |   |
| Sec      | security         |                        |   |   |   |   |   |
| urity:** | framework.       |                        |   |   |   |   |   |
| Fa       |                  |                        |   |   |   |   |   |
| cilitate |                  |                        |   |   |   |   |   |
| ele      |                  |                        |   |   |   |   |   |
| ctronic, |                  |                        |   |   |   |   |   |
| e        |                  |                        |   |   |   |   |   |
| xchange, |                  |                        |   |   |   |   |   |
| access   |                  |                        |   |   |   |   |   |
| and use  |                  |                        |   |   |   |   |   |
| of       |                  |                        |   |   |   |   |   |
| el       |                  |                        |   |   |   |   |   |
| ectronic |                  |                        |   |   |   |   |   |
| health   |                  |                        |   |   |   |   |   |
| inf      |                  |                        |   |   |   |   |   |
| ormation |                  |                        |   |   |   |   |   |
| for      |                  |                        |   |   |   |   |   |
| patients |                  |                        |   |   |   |   |   |
| while    |                  |                        |   |   |   |   |   |
| pr       |                  |                        |   |   |   |   |   |
| otecting |                  |                        |   |   |   |   |   |
| the      |                  |                        |   |   |   |   |   |
| privacy  |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| security |                  |                        |   |   |   |   |   |
| of their |                  |                        |   |   |   |   |   |
| inf      |                  |                        |   |   |   |   |   |
| ormation |                  |                        |   |   |   |   |   |
|          |                  |                        |   |   |   |   |   |
| (        |                  |                        |   |   |   |   |   |
| Measure: |                  |                        |   |   |   |   |   |
| % of     |                  |                        |   |   |   |   |   |
| organ    |                  |                        |   |   |   |   |   |
| izations |                  |                        |   |   |   |   |   |
| with     |                  |                        |   |   |   |   |   |
| policies |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| ap       |                  |                        |   |   |   |   |   |
| proaches |                  |                        |   |   |   |   |   |
| co       |                  |                        |   |   |   |   |   |
| nsistent |                  |                        |   |   |   |   |   |
| with     |                  |                        |   |   |   |   |   |
| confiden |                  |                        |   |   |   |   |   |
| tiality, |                  |                        |   |   |   |   |   |
| privacy, |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| security |                  |                        |   |   |   |   |   |
| fr       |                  |                        |   |   |   |   |   |
| amework) |                  |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.1.2: Identify  | Best practices used to |   |   |   |   |   |
|          | best practices   | develop standards and  |   |   |   |   |   |
|          | to ensure        | certification          |   |   |   |   |   |
|          | confidentiality, | criteria.              |   |   |   |   |   |
|          | integrity, and   |                        |   |   |   |   |   |
|          | availability of  |                        |   |   |   |   |   |
|          | information.     |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.1.3:           | States work            |   |   |   |   |   |
|          | Facilitate       | collaboratively to     |   |   |   |   |   |
|          | state-based      | develop approaches for |   |   |   |   |   |
|          | efforts for      | increased commonality. |   |   |   |   |   |
|          | protected        |                        |   |   |   |   |   |
|          | exchange of      |                        |   |   |   |   |   |
|          | health           |                        |   |   |   |   |   |
|          | information      |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.1.4: Increase  | Stakeholder-specific   |   |   |   |   |   |
|          | stakeholder      | guidance about privacy |   |   |   |   |   |
|          | trust of health  | and security laws.     |   |   |   |   |   |
|          | IT through       |                        |   |   |   |   |   |
|          | education.       |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.1.5: Address   | Published guidance to  |   |   |   |   |   |
|          | apparently       | promote exchange of    |   |   |   |   |   |
|          | inconsistent     | electronic health      |   |   |   |   |   |
|          | statutes and     | information.           |   |   |   |   |   |
|          | regulations for  |                        |   |   |   |   |   |
|          | exchange of      |                        |   |   |   |   |   |
|          | electronic       |                        |   |   |   |   |   |
|          | health           |                        |   |   |   |   |   |
|          | information.     |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
| **1.2 -  | 1.2.1: Advance   | Use by federal         |   |   |   |   |   |
| Int      | use of specified | government entities of |   |   |   |   |   |
| eroperab | data and         | interoperability       |   |   |   |   |   |
| ility:** | technical        | standards.             |   |   |   |   |   |
| Enable   | standards for    |                        |   |   |   |   |   |
| exchange | interoperability |                        |   |   |   |   |   |
| of       |                  |                        |   |   |   |   |   |
| health   |                  |                        |   |   |   |   |   |
| inf      |                  |                        |   |   |   |   |   |
| ormation |                  |                        |   |   |   |   |   |
| to       |                  |                        |   |   |   |   |   |
| support  |                  |                        |   |   |   |   |   |
| p        |                  |                        |   |   |   |   |   |
| atients' |                  |                        |   |   |   |   |   |
| health   |                  |                        |   |   |   |   |   |
| and care |                  |                        |   |   |   |   |   |
| needs    |                  |                        |   |   |   |   |   |
|          |                  |                        |   |   |   |   |   |
| (        |                  |                        |   |   |   |   |   |
| Measure: |                  |                        |   |   |   |   |   |
| % of     |                  |                        |   |   |   |   |   |
| p        |                  |                        |   |   |   |   |   |
| roviders |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| organ    |                  |                        |   |   |   |   |   |
| izations |                  |                        |   |   |   |   |   |
| using    |                  |                        |   |   |   |   |   |
| re       |                  |                        |   |   |   |   |   |
| cognized |                  |                        |   |   |   |   |   |
| interope |                  |                        |   |   |   |   |   |
| rability |                  |                        |   |   |   |   |   |
| s        |                  |                        |   |   |   |   |   |
| tandards |                  |                        |   |   |   |   |   |
| to       |                  |                        |   |   |   |   |   |
| connect  |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| exchange |                  |                        |   |   |   |   |   |
| infor    |                  |                        |   |   |   |   |   |
| mation.) |                  |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.2.2: Identify  | Publicly available     |   |   |   |   |   |
|          | core             | core service           |   |   |   |   |   |
|          | capabilities for | capabilities and data  |   |   |   |   |   |
|          | networks to      | use agreements for     |   |   |   |   |   |
|          | exchange health  | networks to exchange   |   |   |   |   |   |
|          | information.     | health information.    |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.2.3: Foster    | An approach for        |   |   |   |   |   |
|          | the business     | exchange of health     |   |   |   |   |   |
|          | case for         | information in         |   |   |   |   |   |
|          | exchange of      | competitive markets.   |   |   |   |   |   |
|          | health           |                        |   |   |   |   |   |
|          | information.     |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.2.4: Increase  | Providers and provider |   |   |   |   |   |
|          | the volume of    | organizations use NHIN |   |   |   |   |   |
|          | standardized     | specifications for     |   |   |   |   |   |
|          | exchange of      | exchange of health     |   |   |   |   |   |
|          | health           | information.           |   |   |   |   |   |
|          | information to   |                        |   |   |   |   |   |
|          | enhance its      |                        |   |   |   |   |   |
|          | value.           |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.2.5: Promote   | Testing tools and      |   |   |   |   |   |
|          | processes for    | criteria, and          |   |   |   |   |   |
|          | testing          | certification criteria |   |   |   |   |   |
|          | implementation   | are available.         |   |   |   |   |   |
|          | of recognized    |                        |   |   |   |   |   |
|          | standards and    |                        |   |   |   |   |   |
|          | policies.        |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.2.6: Encourage | Consumers have         |   |   |   |   |   |
|          | provision of     | increased access to    |   |   |   |   |   |
|          | electronic       | personal health        |   |   |   |   |   |
|          | personal health  | information through    |   |   |   |   |   |
|          | information in   | interoperable          |   |   |   |   |   |
|          | standardized     | technologies.          |   |   |   |   |   |
|          | form.            |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.2.7: Increase  | Numerous health        |   |   |   |   |   |
|          | the number of    | information service    |   |   |   |   |   |
|          | competitive      | providers.             |   |   |   |   |   |
|          | health           |                        |   |   |   |   |   |
|          | information      |                        |   |   |   |   |   |
|          | service          |                        |   |   |   |   |   |
|          | providers.       |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.2.8 Use        | Standards for a        |   |   |   |   |   |
|          | standards to     | patient's authorized   |   |   |   |   |   |
|          | empower use of   | release to a trusted   |   |   |   |   |   |
|          | health           | entity for non-health  |   |   |   |   |   |
|          | information      | care purposes.         |   |   |   |   |   |
|          | beyond direct    |                        |   |   |   |   |   |
|          | patient care     |                        |   |   |   |   |   |
|          | delivery.        |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+

+----------+------------------+------------------------+---+---+---+---+---+
| **1.3 -  | 1.3.1: Remove    | Physicians using       |   |   |   |   |   |
| Ado      | business         | certified EHRs are     |   |   |   |   |   |
| ption**: | obstacles for    | eligible for           |   |   |   |   |   |
| Promote  | provider use of  | malpractice credit.    |   |   |   |   |   |
| na       | EHRs.            |                        |   |   |   |   |   |
| tionwide |                  |                        |   |   |   |   |   |
| de       |                  |                        |   |   |   |   |   |
| ployment |                  |                        |   |   |   |   |   |
| of EHRs  |                  |                        |   |   |   |   |   |
| and PHRs |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| other    |                  |                        |   |   |   |   |   |
| consumer |                  |                        |   |   |   |   |   |
| health   |                  |                        |   |   |   |   |   |
| IT tools |                  |                        |   |   |   |   |   |
|          |                  |                        |   |   |   |   |   |
| (        |                  |                        |   |   |   |   |   |
| Measure: |                  |                        |   |   |   |   |   |
| % of     |                  |                        |   |   |   |   |   |
| p        |                  |                        |   |   |   |   |   |
| hysician |                  |                        |   |   |   |   |   |
| offices, |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| small    |                  |                        |   |   |   |   |   |
| offices, |                  |                        |   |   |   |   |   |
| using    |                  |                        |   |   |   |   |   |
| c        |                  |                        |   |   |   |   |   |
| ertified |                  |                        |   |   |   |   |   |
| EHR      |                  |                        |   |   |   |   |   |
| systems) |                  |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.3.2: Make EHRs | Available approaches   |   |   |   |   |   |
|          | easy to buy and  | for provider support   |   |   |   |   |   |
|          | implement.       | for EHR adoption.      |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.3.3: Increase  | Certified EHRs with    |   |   |   |   |   |
|          | value of EHRs    | clinical decision      |   |   |   |   |   |
|          | through          | support.               |   |   |   |   |   |
|          | technology.      |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.3.4: Promote   | Majority of products   |   |   |   |   |   |
|          | certified health | are certified.         |   |   |   |   |   |
|          | IT products as   |                        |   |   |   |   |   |
|          | essential to     |                        |   |   |   |   |   |
|          | clinical care.   |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.3.5: Develop   | Study quantifies the   |   |   |   |   |   |
|          | the workforce    | needed workforce.      |   |   |   |   |   |
|          | for health IT    |                        |   |   |   |   |   |
|          | product          |                        |   |   |   |   |   |
|          | development and  |                        |   |   |   |   |   |
|          | use.             |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.3.6: Identify  | Consensus about the    |   |   |   |   |   |
|          | ways for PHRs to | components of a        |   |   |   |   |   |
|          | link to useful   | certified PHR.         |   |   |   |   |   |
|          | health and care  |                        |   |   |   |   |   |
|          | applications.    |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.3.7: Advance   | Creation of a plan to  |   |   |   |   |   |
|          | PHR and consumer | guide PHR development. |   |   |   |   |   |
|          | health IT tools. |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.3.8: Minimize  | Increased provider     |   |   |   |   |   |
|          | provider         | understanding of       |   |   |   |   |   |
|          | liability when   | health IT liability    |   |   |   |   |   |
|          | using health IT. | risks as evidenced     |   |   |   |   |   |
|          |                  | through research       |   |   |   |   |   |
|          |                  | results.               |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.3.9: Remove    | Published results of   |   |   |   |   |   |
|          | barriers to      | public/private         |   |   |   |   |   |
|          | treating         | collaborations         |   |   |   |   |   |
|          | patients outside | supporting secure      |   |   |   |   |   |
|          | of provider      | messaging pilots.      |   |   |   |   |   |
|          | offices.         |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
| **1.4 -  | 1.4.1: Establish | A public-private       |   |   |   |   |   |
| Colla    | an entity to     | entity oversees        |   |   |   |   |   |
| borative | advance          | nationwide exchange of |   |   |   |   |   |
| Gover    | nationwide       | health information.    |   |   |   |   |   |
| nance:** | exchange of      |                        |   |   |   |   |   |
| E        | health           |                        |   |   |   |   |   |
| stablish | information.     |                        |   |   |   |   |   |
| me       |                  |                        |   |   |   |   |   |
| chanisms |                  |                        |   |   |   |   |   |
| for      |                  |                        |   |   |   |   |   |
| m        |                  |                        |   |   |   |   |   |
| ulti-sta |                  |                        |   |   |   |   |   |
| keholder |                  |                        |   |   |   |   |   |
| priority |                  |                        |   |   |   |   |   |
| -setting |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| decisio  |                  |                        |   |   |   |   |   |
| n-making |                  |                        |   |   |   |   |   |
|          |                  |                        |   |   |   |   |   |
| (        |                  |                        |   |   |   |   |   |
| Measure: |                  |                        |   |   |   |   |   |
| Estab    |                  |                        |   |   |   |   |   |
| lishment |                  |                        |   |   |   |   |   |
| of       |                  |                        |   |   |   |   |   |
| self-su  |                  |                        |   |   |   |   |   |
| staining |                  |                        |   |   |   |   |   |
| AHIC     |                  |                        |   |   |   |   |   |
| su       |                  |                        |   |   |   |   |   |
| ccessor) |                  |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.4.2: Assure    | Consumer participation |   |   |   |   |   |
|          | consumer         | in activities related  |   |   |   |   |   |
|          | representation   | to the exchange of     |   |   |   |   |   |
|          | in stakeholder   | health information.    |   |   |   |   |   |
|          | governance.      |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+
|          | 1.4.3: Promote   | Mechanisms enable      |   |   |   |   |   |
|          | active and       | federal, state, and    |   |   |   |   |   |
|          | appropriate      | local governance       |   |   |   |   |   |
|          | participation by | entities to have input |   |   |   |   |   |
|          | all relevant     | into decision-making   |   |   |   |   |   |
|          | government       | processes.             |   |   |   |   |   |
|          | agencies in      |                        |   |   |   |   |   |
|          | m                |                        |   |   |   |   |   |
|          | ulti-stakeholder |                        |   |   |   |   |   |
|          | governance       |                        |   |   |   |   |   |
|          | entities         |                        |   |   |   |   |   |
|          | activities.      |                        |   |   |   |   |   |
+----------+------------------+------------------------+---+---+---+---+---+

+----------+------------------+------------------------+---+---+---+---+---+
| **Goal   |                  |                        |   |   |   |   |   |
| 1:       |                  |                        |   |   |   |   |   |
| Patient  |                  |                        |   |   |   |   |   |
| -focused |                  |                        |   |   |   |   |   |
| Health   |                  |                        |   |   |   |   |   |
| Care**   |                  |                        |   |   |   |   |   |
|          |                  |                        |   |   |   |   |   |
| **Enable |                  |                        |   |   |   |   |   |
| the      |                  |                        |   |   |   |   |   |
| transf   |                  |                        |   |   |   |   |   |
| ormation |                  |                        |   |   |   |   |   |
| to       |                  |                        |   |   |   |   |   |
| higher   |                  |                        |   |   |   |   |   |
| quality, |                  |                        |   |   |   |   |   |
| more     |                  |                        |   |   |   |   |   |
| ef       |                  |                        |   |   |   |   |   |
| ficient, |                  |                        |   |   |   |   |   |
| patient  |                  |                        |   |   |   |   |   |
| -focused |                  |                        |   |   |   |   |   |
| health   |                  |                        |   |   |   |   |   |
| care     |                  |                        |   |   |   |   |   |
| through  |                  |                        |   |   |   |   |   |
| el       |                  |                        |   |   |   |   |   |
| ectronic |                  |                        |   |   |   |   |   |
| health   |                  |                        |   |   |   |   |   |
| inf      |                  |                        |   |   |   |   |   |
| ormation |                  |                        |   |   |   |   |   |
| access   |                  |                        |   |   |   |   |   |
| and use  |                  |                        |   |   |   |   |   |
| by care  |                  |                        |   |   |   |   |   |
| p        |                  |                        |   |   |   |   |   |
| roviders |                  |                        |   |   |   |   |   |
| and by   |                  |                        |   |   |   |   |   |
| patients |                  |                        |   |   |   |   |   |
| and      |                  |                        |   |   |   |   |   |
| their    |                  |                        |   |   |   |   |   |
| des      |                  |                        |   |   |   |   |   |
| ignees** |                  |                        |   |   |   |   |   |
+==========+==================+========================+===+===+===+===+===+
| **Obj    | **Strategy**     | **Milestone**          | * | * | * | * | * |
| ective** |                  |                        | * | * | * | * | * |
|          |                  |                        | 2 | 2 | 2 | 2 | 2 |
|          |                  |                        | 0 | 0 | 0 | 0 | 0 |
|          |                  |                        | 0 | 0 | 1 | 1 | 1 |
|          |                  |                        | 8 | 9 | 0 | 1 | 2 |
|          |                  |                        | * | * | * | * | * |
|          |                  |                        | * | * | * | * | * |
+----------+------------------+------------------------+---+---+---+---+---+

+---------+----------------------+---------------------+---+---+---+---+---+
| **Goal  |                      |                     |   |   |   |   |   |
| 2:      |                      |                     |   |   |   |   |   |
| Pop     |                      |                     |   |   |   |   |   |
| ulation |                      |                     |   |   |   |   |   |
| H       |                      |                     |   |   |   |   |   |
| ealth** |                      |                     |   |   |   |   |   |
|         |                      |                     |   |   |   |   |   |
| *       |                      |                     |   |   |   |   |   |
| *Enable |                      |                     |   |   |   |   |   |
| the     |                      |                     |   |   |   |   |   |
| appro   |                      |                     |   |   |   |   |   |
| priate, |                      |                     |   |   |   |   |   |
| auth    |                      |                     |   |   |   |   |   |
| orized, |                      |                     |   |   |   |   |   |
| and     |                      |                     |   |   |   |   |   |
| timely  |                      |                     |   |   |   |   |   |
| access  |                      |                     |   |   |   |   |   |
| and use |                      |                     |   |   |   |   |   |
| of      |                      |                     |   |   |   |   |   |
| ele     |                      |                     |   |   |   |   |   |
| ctronic |                      |                     |   |   |   |   |   |
| health  |                      |                     |   |   |   |   |   |
| info    |                      |                     |   |   |   |   |   |
| rmation |                      |                     |   |   |   |   |   |
| to      |                      |                     |   |   |   |   |   |
| benefit |                      |                     |   |   |   |   |   |
| public  |                      |                     |   |   |   |   |   |
| health, |                      |                     |   |   |   |   |   |
| bio     |                      |                     |   |   |   |   |   |
| medical |                      |                     |   |   |   |   |   |
| re      |                      |                     |   |   |   |   |   |
| search, |                      |                     |   |   |   |   |   |
| quality |                      |                     |   |   |   |   |   |
| impro   |                      |                     |   |   |   |   |   |
| vement, |                      |                     |   |   |   |   |   |
| and     |                      |                     |   |   |   |   |   |
| em      |                      |                     |   |   |   |   |   |
| ergency |                      |                     |   |   |   |   |   |
| p       |                      |                     |   |   |   |   |   |
| repared |                      |                     |   |   |   |   |   |
| ness.** |                      |                     |   |   |   |   |   |
+=========+======================+=====================+===+===+===+===+===+
| **Obje  | **Strategy**         | **Milestones**      | * | * | * | * | * |
| ctive** |                      |                     | * | * | * | * | * |
|         |                      |                     | 2 | 2 | 2 | 2 | 2 |
|         |                      |                     | 0 | 0 | 0 | 0 | 0 |
|         |                      |                     | 0 | 0 | 1 | 1 | 1 |
|         |                      |                     | 8 | 9 | 0 | 1 | 2 |
|         |                      |                     | * | * | * | * | * |
|         |                      |                     | * | * | * | * | * |
+---------+----------------------+---------------------+---+---+---+---+---+
| **2.1 - | 2.1.1:Employ the     | Publication of      |   |   |   |   |   |
| Privacy | privacy and security | privacy and         |   |   |   |   |   |
| and     | framework (see       | security framework  |   |   |   |   |   |
| Secu    | Strategy 1.1.1) for  | with engagement of  |   |   |   |   |   |
| rity:** | population health    | population health   |   |   |   |   |   |
| Advance | information.         | stakeholders.       |   |   |   |   |   |
| prin    |                      |                     |   |   |   |   |   |
| ciples, |                      |                     |   |   |   |   |   |
| proc    |                      |                     |   |   |   |   |   |
| edures, |                      |                     |   |   |   |   |   |
| and     |                      |                     |   |   |   |   |   |
| prot    |                      |                     |   |   |   |   |   |
| ections |                      |                     |   |   |   |   |   |
| for     |                      |                     |   |   |   |   |   |
| info    |                      |                     |   |   |   |   |   |
| rmation |                      |                     |   |   |   |   |   |
| access  |                      |                     |   |   |   |   |   |
| in      |                      |                     |   |   |   |   |   |
| pop     |                      |                     |   |   |   |   |   |
| ulation |                      |                     |   |   |   |   |   |
| health  |                      |                     |   |   |   |   |   |
|         |                      |                     |   |   |   |   |   |
| (M      |                      |                     |   |   |   |   |   |
| easure: |                      |                     |   |   |   |   |   |
| % of    |                      |                     |   |   |   |   |   |
| federal |                      |                     |   |   |   |   |   |
| organi  |                      |                     |   |   |   |   |   |
| zations |                      |                     |   |   |   |   |   |
| a       |                      |                     |   |   |   |   |   |
| dhering |                      |                     |   |   |   |   |   |
| to      |                      |                     |   |   |   |   |   |
| pri     |                      |                     |   |   |   |   |   |
| nciples |                      |                     |   |   |   |   |   |
| ex      |                      |                     |   |   |   |   |   |
| pressed |                      |                     |   |   |   |   |   |
| in      |                      |                     |   |   |   |   |   |
| co      |                      |                     |   |   |   |   |   |
| nfident |                      |                     |   |   |   |   |   |
| iality, |                      |                     |   |   |   |   |   |
| privacy |                      |                     |   |   |   |   |   |
| and     |                      |                     |   |   |   |   |   |
| s       |                      |                     |   |   |   |   |   |
| ecurity |                      |                     |   |   |   |   |   |
| fram    |                      |                     |   |   |   |   |   |
| ework.) |                      |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.1.2: Address       | Identification of   |   |   |   |   |   |
|         | apparently           | conflicts and       |   |   |   |   |   |
|         | inconsistent         | appropriate actions |   |   |   |   |   |
|         | statutes or          | taken.              |   |   |   |   |   |
|         | regulations for      |                     |   |   |   |   |   |
|         | exchange of          |                     |   |   |   |   |   |
|         | population health    |                     |   |   |   |   |   |
|         | information.         |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.1.3: Facilitate    | Guidance published  |   |   |   |   |   |
|         | state-based efforts  | for states.         |   |   |   |   |   |
|         | for protected        |                     |   |   |   |   |   |
|         | exchange of          |                     |   |   |   |   |   |
|         | population health    |                     |   |   |   |   |   |
|         | information.         |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.1.4: Increase      | Federal agencies    |   |   |   |   |   |
|         | stakeholder          | work with           |   |   |   |   |   |
|         | understanding of     | stakeholders to     |   |   |   |   |   |
|         | current federal      | identify issues and |   |   |   |   |   |
|         | privacy and security | clarify laws.       |   |   |   |   |   |
|         | laws.                |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
| **2.2 - | 2.2.1: Advance       | Population health   |   |   |   |   |   |
| Inter   | standards to support | information users   |   |   |   |   |   |
| operabi | the merging of       | will receive        |   |   |   |   |   |
| lity:** | comparable           | comparable data     |   |   |   |   |   |
| Enable  | population health    | from clinical       |   |   |   |   |   |
| e       | information.         | sources.            |   |   |   |   |   |
| xchange |                      |                     |   |   |   |   |   |
| of      |                      |                     |   |   |   |   |   |
| health  |                      |                     |   |   |   |   |   |
| info    |                      |                     |   |   |   |   |   |
| rmation |                      |                     |   |   |   |   |   |
| to      |                      |                     |   |   |   |   |   |
| support |                      |                     |   |   |   |   |   |
| popul   |                      |                     |   |   |   |   |   |
| ation-o |                      |                     |   |   |   |   |   |
| riented |                      |                     |   |   |   |   |   |
| uses    |                      |                     |   |   |   |   |   |
|         |                      |                     |   |   |   |   |   |
| (M      |                      |                     |   |   |   |   |   |
| easure: |                      |                     |   |   |   |   |   |
| % of    |                      |                     |   |   |   |   |   |
| pop     |                      |                     |   |   |   |   |   |
| ulation |                      |                     |   |   |   |   |   |
| health  |                      |                     |   |   |   |   |   |
| a       |                      |                     |   |   |   |   |   |
| gencies |                      |                     |   |   |   |   |   |
| using   |                      |                     |   |   |   |   |   |
| rec     |                      |                     |   |   |   |   |   |
| ognized |                      |                     |   |   |   |   |   |
| in      |                      |                     |   |   |   |   |   |
| teroper |                      |                     |   |   |   |   |   |
| ability |                      |                     |   |   |   |   |   |
| st      |                      |                     |   |   |   |   |   |
| andards |                      |                     |   |   |   |   |   |
| to      |                      |                     |   |   |   |   |   |
| e       |                      |                     |   |   |   |   |   |
| xchange |                      |                     |   |   |   |   |   |
| infor   |                      |                     |   |   |   |   |   |
| mation) |                      |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.2.2: Enable        | Three models for    |   |   |   |   |   |
|         | flexible models for  | exchange of         |   |   |   |   |   |
|         | exchange of          | population health   |   |   |   |   |   |
|         | population health    | information are     |   |   |   |   |   |
|         | information.         | supported.          |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.2.3: Assess        | Electronic          |   |   |   |   |   |
|         | providers\' and      | verification        |   |   |   |   |   |
|         | networks\'           | capabilities will   |   |   |   |   |   |
|         | implementation of    | ensure consistent   |   |   |   |   |   |
|         | standards.           | use of standards.   |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.2.4: Promote       | Networks provide    |   |   |   |   |   |
|         | availability of      | population health   |   |   |   |   |   |
|         | population health    | information using   |   |   |   |   |   |
|         | information in       | NHIN                |   |   |   |   |   |
|         | electronic form.     | specifications.     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.2.5: Provide       | Networks using NHIN |   |   |   |   |   |
|         | population health    | specifications      |   |   |   |   |   |
|         | information needed   | provide population  |   |   |   |   |   |
|         | for emergency        | health information  |   |   |   |   |   |
|         | response.            | for emergency       |   |   |   |   |   |
|         |                      | response.           |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
| **2.3 - | 2.3.1: Optimize      | Increased           |   |   |   |   |   |
| Adop    | exchange of EHR and  | automation of       |   |   |   |   |   |
| tion:** | population health    | clinical            |   |   |   |   |   |
| Promote | information among    | information sent    |   |   |   |   |   |
| nat     | users.               | and accessed by     |   |   |   |   |   |
| ionwide |                      | providers.          |   |   |   |   |   |
| a       |                      |                     |   |   |   |   |   |
| doption |                      |                     |   |   |   |   |   |
| of      |                      |                     |   |   |   |   |   |
| techn   |                      |                     |   |   |   |   |   |
| ologies |                      |                     |   |   |   |   |   |
| to      |                      |                     |   |   |   |   |   |
| improve |                      |                     |   |   |   |   |   |
| pop     |                      |                     |   |   |   |   |   |
| ulation |                      |                     |   |   |   |   |   |
| and     |                      |                     |   |   |   |   |   |
| ind     |                      |                     |   |   |   |   |   |
| ividual |                      |                     |   |   |   |   |   |
| health  |                      |                     |   |   |   |   |   |
|         |                      |                     |   |   |   |   |   |
| (M      |                      |                     |   |   |   |   |   |
| easure: |                      |                     |   |   |   |   |   |
| % of    |                      |                     |   |   |   |   |   |
| pop     |                      |                     |   |   |   |   |   |
| ulation |                      |                     |   |   |   |   |   |
| health  |                      |                     |   |   |   |   |   |
| info    |                      |                     |   |   |   |   |   |
| rmation |                      |                     |   |   |   |   |   |
| that is |                      |                     |   |   |   |   |   |
| re-used |                      |                     |   |   |   |   |   |
| without |                      |                     |   |   |   |   |   |
| manual  |                      |                     |   |   |   |   |   |
| interve |                      |                     |   |   |   |   |   |
| ntion.) |                      |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.3.2: Minimize      | Certified EHRs will |   |   |   |   |   |
|         | provider burden for  | have automated      |   |   |   |   |   |
|         | population health    | "upstream" data     |   |   |   |   |   |
|         | reporting.           | transmission.       |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.3.3: Electronic    | Pilot projects      |   |   |   |   |   |
|         | exchange of          | underway for        |   |   |   |   |   |
|         | population health    | population health   |   |   |   |   |   |
|         | data among various   | data exchange.      |   |   |   |   |   |
|         | stakeholders.        |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
| **2.4 - | 2.4.1: Advance data  | Data stewardship    |   |   |   |   |   |
| Collab  | stewardship models   | models supporting   |   |   |   |   |   |
| orative | for exchange of      | pilots of exchange  |   |   |   |   |   |
| Govern  | population health    | of population       |   |   |   |   |   |
| ance:** | information.         | health information. |   |   |   |   |   |
| Es      |                      |                     |   |   |   |   |   |
| tablish |                      |                     |   |   |   |   |   |
| coor    |                      |                     |   |   |   |   |   |
| dinated |                      |                     |   |   |   |   |   |
| organiz |                      |                     |   |   |   |   |   |
| ational |                      |                     |   |   |   |   |   |
| pr      |                      |                     |   |   |   |   |   |
| ocesses |                      |                     |   |   |   |   |   |
| sup     |                      |                     |   |   |   |   |   |
| porting |                      |                     |   |   |   |   |   |
| info    |                      |                     |   |   |   |   |   |
| rmation |                      |                     |   |   |   |   |   |
| use for |                      |                     |   |   |   |   |   |
| pop     |                      |                     |   |   |   |   |   |
| ulation |                      |                     |   |   |   |   |   |
| health  |                      |                     |   |   |   |   |   |
|         |                      |                     |   |   |   |   |   |
| (M      |                      |                     |   |   |   |   |   |
| easure: |                      |                     |   |   |   |   |   |
| % of    |                      |                     |   |   |   |   |   |
| gov     |                      |                     |   |   |   |   |   |
| ernance |                      |                     |   |   |   |   |   |
| e       |                      |                     |   |   |   |   |   |
| ntities |                      |                     |   |   |   |   |   |
| that    |                      |                     |   |   |   |   |   |
| comply  |                      |                     |   |   |   |   |   |
| with    |                      |                     |   |   |   |   |   |
| c       |                      |                     |   |   |   |   |   |
| onsensu |                      |                     |   |   |   |   |   |
| s-based |                      |                     |   |   |   |   |   |
| pol     |                      |                     |   |   |   |   |   |
| icies.) |                      |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.4.2: Implement     | Quality measures    |   |   |   |   |   |
|         | quality measures in  | are electronically  |   |   |   |   |   |
|         | ways compatible with | reported to         |   |   |   |   |   |
|         | different models for | providers.          |   |   |   |   |   |
|         | exchange of health   |                     |   |   |   |   |   |
|         | information.         |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.4.3: Connect       | Public health       |   |   |   |   |   |
|         | clinical care and    | priorities are      |   |   |   |   |   |
|         | public health        | advanced through    |   |   |   |   |   |
|         | through exchange of  | coordinated         |   |   |   |   |   |
|         | electronic health    | governance by AHIC  |   |   |   |   |   |
|         | information.         | Successor.          |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.4.4: Connect       | Demonstrated        |   |   |   |   |   |
|         | clinical care and    | coordination of     |   |   |   |   |   |
|         | research through     | governance across   |   |   |   |   |   |
|         | exchange of          | clinical care and   |   |   |   |   |   |
|         | electronic health    | research            |   |   |   |   |   |
|         | information.         | communities.        |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.4.5: Create        | Accreditation       |   |   |   |   |   |
|         | accountability for   | criteria for        |   |   |   |   |   |
|         | implementing         | electronic exchange |   |   |   |   |   |
|         | exchange of          | of health           |   |   |   |   |   |
|         | electronic health    | information.        |   |   |   |   |   |
|         | information.         |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+
|         | 2.4.6: Develop,      | Federal health data |   |   |   |   |   |
|         | implement, and       | are shared securely |   |   |   |   |   |
|         | oversee health data  | across federal      |   |   |   |   |   |
|         | sharing strategy     | agencies.           |   |   |   |   |   |
|         | across federal       |                     |   |   |   |   |   |
|         | agencies.            |                     |   |   |   |   |   |
+---------+----------------------+---------------------+---+---+---+---+---+

**Goal One -- *Enable Patient-focused Health Care***

**Enable the transformation to higher-quality, more cost-efficient,
patient-focused health care through electronic health information access
and use by care providers, and by patients and their designees.**

Goal One of the Plan focuses on the processes of health care that
primarily involve interactions between patients and care providers, but
increasingly reflect activities of individuals to promote their own
health and well-being. Secure access to information by providers and
patients can promote health care that is reflective of best practices,
safer, and thus more cost-efficient. Informed patients will be able to
make better choices and decisions toward maintaining a healthier
lifestyle, potentially preventing debilitating and costly illnesses.
Empowering patients to direct their health information, to be used in
support of the patient's needs beyond direct health care, will bring
far-reaching benefits.

The Plan articulates four objectives that support the accomplishment of
this goal. Through the achievement of all four objectives, with progress
toward each objective occurring in parallel, the health care system can
be transformed. In their simplified form, the objectives are:

> ***Objective 1.1 -- Privacy and Security:*** Facilitate electronic
> exchange, access, and use of electronic health information, while
> protecting the privacy and security of patients' health information
>
> ***Objective 1.2 --* *Interoperability:*** Enable the movement of
> electronic health information to where and when it is needed to
> support individual health and care needs
>
> ***Objective 1.3 -- Adoption:*** Promote nationwide deployment of
> electronic health records and personal health records that put
> information to use in support of health and care
>
> ***Objective 1.4 -- Collaborative Governance:*** Establish mechanisms
> for multi-stakeholder priority-setting and decision-making to guide
> the development of the nation's interoperable health IT architecture

These objectives work together to achieve the vision of Executive Order
13335 and the vision that most Americans will have electronic health
records by 2014.

**[Objective 1.1]{.underline} -- *Privacy and Security:* Identify any
policy issues, gaps or barriers\--and advance the development of
approaches\--to facilitate the electronic exchange, access, and use of
health information, while protecting the privacy and security of
patients' health information.**

> **Measure:** Percentage of organizations that electronically exchange
> health information for health care delivery and that develop their
> policies and implementation approaches consistent with a nationwide
> confidentiality, privacy, and security framework. (Developmental.)
>
> **Target:** To be determined, pending review of baseline data
> collected in 2010.
>
> **Method:** Annual survey of a scientific sample of health care
> organizations.

**Discussion**

To guide evolving technology, careful attention to privacy and security
policies, at the federal and state levels, is needed to ensure that
nationwide interoperable health IT is achieved with a high degree of
public confidence and trust. The adoption of baseline and common
confidentiality, privacy, and security protections is essential to
building that trust among involved patients and other stakeholders.
Application of these protections by entities engaged in electronic
exchange of health information can help foster the adoption of health
IT. Addressing many of the policy issues regarding electronic
disclosure, access, and use of health information, while ensuring that
privacy and security protections are in place, will facilitate the
electronic exchange, access, and use of health information for health
care delivery.

-   Assuring the integrity of the health information being exchanged,
    accessed, and used by providers and patients can lead to higher
    quality care. Establishing national principles for health
    information security and stewardship will allow providers to trust
    that the information they use when assessing and treating patients
    is as accurate as possible and has not been accessed by unauthorized
    users.

-   Harmonizing privacy and security policies across care settings and
    communities can help facilitate the appropriate exchange of health
    information and increase consistent protections for health
    information. Providers and patients will be able to easily access
    and use health information when and where it is needed while being
    assured that only those who are authorized have access to this
    information.

-   Ensuring that all stakeholders are aware of patient privacy rights,
    and that patient perspectives are included and addressed when
    organizations develop privacy and security policies and
    implementation approaches, can promote patient-focused care. By
    involving patients and patient advocates in the policy development
    process -- at federal, state, local, and organizational levels --
    all stakeholders will be better informed about patient privacy
    rights and patient preferences, and this, in turn, will increase
    trust in nationwide exchange of health information.

-   Patient-focused care is dependent on patients having access to their
    own information. The use of personal health records by health care
    consumers is expected to increase in proportion to the trust they
    place in the protections of their information being exchanged
    electronically.

**Strategies**

Five strategies work in combination to achieve this objective. The
strategies are shaped by the President's Executive Order 13335 which
requires the Strategic Plan to address privacy and security issues
related to health IT. (Details in Appendix A beginning on Page A1.)

**Strategy 1.1.1**: Develop a confidentiality, privacy, and security
framework for policy development to promote patient and consumer trust
in, and advance the electronic exchange of, health information.

> *Privacy and security policies currently differ between the federal
> and state levels, across states, across organizations, and among
> distinct stakeholders and users of information. In addition, new
> issues raised by electronic exchange of health information are best
> resolved through a comprehensive framework for all stakeholders to
> consider these issues and develop consistent policies for exchange of
> health information. Building from HIPAA and other existing privacy and
> security laws, such as the Privacy Act and the Federal Information
> Security Management Act, a framework of policy principles, developed
> at the federal level, can guide organizations in establishing policies
> for the exchange of electronic health information that apply the same
> baseline protections for patient information, supporting needed
> exchange across organizations and jurisdictions.*

**Strategy 1.1.2:** Identify best practices for implementing technical
solutions to ensure confidentiality, integrity, and availability of
electronic health information consistent with the confidentiality,
privacy and security framework.

> *Technical solutions are an important means to put into practice the
> principles established by the confidentiality, privacy, and security
> framework. Identifying and implementing best practices and common
> approaches for technical solutions to ensure confidentiality,
> integrity, and availability of electronic health information can
> support higher quality care as providers and patients make decisions
> based on the most accurate and complete information.*

**Strategy 1.1.3:** Facilitate state-based activities to identify and
address challenges to the use of health information technology, and the
intra- and inter-jurisdictional exchange of electronic health
information, while preserving or enhancing the current level of patient
protections.

> *Many state laws that address or impact the privacy or the disclosure
> of electronic health information were written before interoperable
> health IT and the widespread exchange of electronic health information
> were feasible and, as such, may inadvertently and unnecessarily
> prohibit or significantly limit the appropriate exchange of electronic
> health information. In addition, certain conflicts and inconsistencies
> exist among these various statutes, regulations, and policies, whether
> perceived or real, that present further challenges to appropriate
> electronic exchange of health information. These conflicts and
> inconsistencies can lead to reduced quality of care and inefficiencies
> in health care delivery when health care providers choose not to share
> information for treatment purposes because they are reluctant to risk
> non-compliance with laws or policies they do not fully understand.
> Through a variety of forums, the federal government has and will
> continue to foster federal and state collaboration and coordination on
> patient protections while considering approaches that also enable the
> exchange of health information to promote greater quality and
> efficiency of health care delivery.*

**Strategy 1.1.4:** Increase stakeholder understanding of current
federal health privacy and security statutes and regulations in order to
promote trust in the use of health information technology and the
exchange of electronic health information for health care treatment
purposes.

> *Successful transformation to a patient-focused health care delivery
> system is dependent on public trust in efficient exchange of
> electronic health information for treatment purposes. This strategy
> supports educating all stakeholders involved in health care delivery
> -- particularly those that hold patient health information -- about
> the protections afforded by federal health privacy and security
> policies. This educational effort, in addition to increasing patients'
> understanding of their privacy rights, should foster patients' trust
> that their information will remain private and secure.*

**Strategy 1.1.5:** Identify and evaluate approaches to address federal
statutes or regulations that conflict or are inconsistent -- or are
perceived to conflict or be inconsistent \-- with the exchange of
electronic health information for health care delivery, while preserving
or enhancing patient protections.

> *Some federal statutes and regulations that were written before health
> IT and exchange of electronic health information were contemplated may
> inadvertently and unnecessarily limit the electronic exchange of
> health information for health care delivery. These limitations --
> actual or perceived -- can prevent providers from having all the
> information they need about a patient at the point of care. This
> strategy promotes a collaborative approach to crafting solutions that
> maintain an appropriate level of privacy and security of patient
> information while enabling appropriate exchange, access, and use of
> electronic health information.*

**Recent Federal Government Progress**

Several federal agencies are involved in multiple initiatives that will
advance this objective. This work has at times been informed by certain
federal advisory body recommendations that were submitted to the
Secretary of HHS. Table 1.1 provides a list of these initiatives along
with the appendix page where a summary of each can be found. Activities
focus on offering guidance and clarifications regarding privacy
protections for electronic health data and exchange of health
information to support care delivery, identifying variation in states'
privacy and security common approaches and practices, identifying
mechanisms to foster compatibility of these common approaches and
practices, and ensuring appropriate privacy and security protections are
included in emerging infrastructures for exchange of health information.

+-----------------------------------------------------------------------+
| **Table 1.1 -- Current Health IT Initiatives and Federal Advisory     |
| Committees Addressing Objective 1.1**                                 |
+-----------------------------------------------------------------------+
| **Federal Agency and Department Initiatives**                         |
+-----------------------------------------------------------------------+
| > **AHRQ:** Health IT Portfolio (Page A30)                            |
+-----------------------------------------------------------------------+
| > **CMS:** HIPAA Security Rule (Page A35)                             |
+-----------------------------------------------------------------------+
| > **NIST:** Security Technology (Page A55)                            |
+-----------------------------------------------------------------------+
| > **OCR:** HIPAA Privacy Rule and Health IT (Page A45)                |
+-----------------------------------------------------------------------+
| > **ONC:** Anti-Fraud Activities (Page A46), Certification Commission |
| > for Healthcare Information Technology (CCHIT: Page A46), Health     |
| > Information Security and Privacy Collaborative (HISPC: Page A47),   |
| > Healthcare Information Technology Standards Panel (HITSP: Page      |
| > A47), Nationwide Health Information Network (NHIN: Page A47), State |
| > Alliance for e-Health (Page A48)                                    |
+-----------------------------------------------------------------------+
| > **SAMHSA:** Health IT Initiatives (Page A54)                        |
+-----------------------------------------------------------------------+
| **Federal Advisory Committees**                                       |
+-----------------------------------------------------------------------+
| > National Committee on Vital and Health Statistics (NCVHS: Page A62) |
+-----------------------------------------------------------------------+
| > American Health Information Community (AHIC: Page A63), with its    |
| > workgroup on Confidentiality, Privacy, and Security (Page A64)      |
+-----------------------------------------------------------------------+

**\*\*\*\***

**[Objective 1.2]{.underline} -- *Interoperability:* Enable the exchange
of interoperable health information among health care providers and
organizations, as well as patients and their designees, to support
patients' health and care needs.**

> **Measure:** Percentage of providers and provider organizations with
> EHRs using recognized interoperability standards and NHIN
> specifications to connect their health information systems and
> exchange health information in support of care delivery.
> (Developmental.)
>
> **Target:** To be determined, pending review of baseline data
> collected in 2010[^1].
>
> **Method:** Annual national survey of a scientific sample of providers
> and provider organizations.

**Discussion**

Advancing recognized data and technical standards, policies, and
networking is essential to promoting interoperability of health IT
solutions. The resulting ability to exchange health information supports
progress toward more efficient and informed care delivery, care
coordination, communication among providers, and individual care
management.

-   Sharing health information across multiple care settings can
    increase care coordination and lead to greater efficiency. Employing
    recognized data and technical standards facilitates interoperability
    and the transfer and use of this information. By increasing the
    number of entities that support these recognized interoperability
    standards and meet minimum policies and principles, providers and
    patients will be able to easily access and use health information
    when and where it is needed. Duplication of services can be reduced
    as information flows seamlessly across organizational borders.
    [Presidential Executive Order
    13410](http://www.whitehouse.gov/news/releases/2006/08/20060822-2.html)
    is an example of efforts to increase the federal government's use of
    interoperable systems and harmonized standards. This Order seeks to
    ensure that health care programs administered or sponsored by the
    federal government promote quality and efficient delivery of health
    care through the use of interoperable health IT, transparency
    regarding health care quality and price, and better incentives for
    program beneficiaries, enrollees, and providers.

-   Exchange of health information using interoperable systems can bring
    about higher quality of care*.* Secure and reliable access to the
    most comprehensive and current patient information can help
    providers and patients make more informed decisions. Providers and
    patients can be assured that consistent information is shared
    through the use of standards in health systems. The Nationwide
    Health Information Network (NHIN) is a public-private endeavor to
    use standards and information exchange approaches for participating
    networks and entities, which have been developed by voluntary
    consensus standards bodies for exchange of health information among
    all such entities and networks. It is an approach to establishing an
    interoperable infrastructure among distinct networks that allows for
    different approaches and implementations, while ensuring secure
    information exchange as needed for patient care and population
    health.

**Strategies**

Eight strategies work in combination to achieve the objective of
enabling the exchange of interoperable health information to support
patients' health and care needs. Several of the strategies under the two
interoperability objectives -- 1.2 and 2.2 -- are similar due to the
needs for a shared information infrastructure for health care and
population health purposes including occupational safety, public health,
and emergency preparedness.  Health care providers and population health
information users also have unique needs that must be addressed by the
infrastructure, making certain aspects of these strategies distinct.
(Details in Appendix A beginning on Page A4.) 

**Strategy 1.2.1:** Advance the identification, availability and use of
specified data and technical standards for interoperability that meet
critical provider and individual information needs.

> *The ability to readily share information among providers and with
> patients is critical to improving care coordination and quality of
> care. The infrastructure necessary to support this exchange involves
> incorporating recognized interoperability data and technical standards
> into health IT products and systems to support multiple and different
> care settings (such as an emergency room and a cardiologist's office)
> as well as personal health records. The ability of providers and
> individuals to use dissimilar health IT systems and networks to
> reliably and securely exchange health information is dependent upon
> these interoperability specifications or standards.*

**Strategy 1.2.2:** Identify core capabilities and governance necessary
for networks to work with other networks in support of secure exchange
of electronic health information using non-proprietary standards.

> *If networks employ some common network capabilities, interoperable
> data and technical standards to support them, and common governance
> principles, providers will be able to efficiently communicate and
> share patient information, as appropriate and necessary, regardless of
> the network they use. However, solutions and networks for exchanging
> health information have frequently been developed to meet specific,
> often proprietary, needs. Each solution frequently has had an
> individualized set of technologies, policies, and governance. Strategy
> 1.2.2 seeks to increase the number of networks able to easily and
> securely exchange information with other networks.*

**Strategy 1.2.3:** Foster the business case for self-sustaining
exchange of health information in communities, states, and nationwide.

> *Sustainable exchange of health information among different networks
> in communities and across regions and states can improve quality,
> patient-focused health care, and patients' overall health status. A
> number of challenges to the evolution of interoperable technology,
> networks, and services exist. To mitigate these challenges, federal
> and state governments need to consider and evaluate policy options
> that encourage exchange of health information among federal, regional,
> state, and specialty networks that use recognized interoperability
> standards and NHIN specifications. The advancement of business drivers
> for the exchange of health information will enable quality improvement
> and efficiencies in care delivery by solidifying the demonstrable
> outcomes, financial stability, and infrastructure support for the
> non-proprietary exchange of health information to support care.*

**Strategy 1.2.4:** Increase the amount of health information being
exchanged electronically using the specified standards for exchange of
health information -- to enhance the value for other providers, provider
organizations, and networks to adopt the standards.

> *Achieving a critical mass of providers who use standards-based
> electronic exchange of health information is important to promoting
> widespread adoption of interoperable health IT. When few providers are
> using interoperable health IT, other providers and patients are less
> likely to invest in interoperable systems. As a result, the utility of
> the health information and existing networks, including quality and
> cost-efficiency improvements in care delivery, are not maximized. The
> federal government, with support from relevant stakeholders, will
> enhance health information available for exchange and support a range
> of approaches and models designed to support shared, standards-based
> exchange of health information. An NHIN that connects several models
> of information exchange through the use of interoperability standards
> and specifications will increase the cost-efficiency of care delivery
> by enabling greater information exchange across more diverse users and
> settings.*

**Strategy 1.2.5:** Promote the development of the processes and
infrastructure for testing, verification, and implementation of
recognized standards and services, and nationwide policies in networks,
connected systems, and health IT.

> *Verification of the accurate implementation and use of data and
> technical standards is critical to increasing the interoperability of
> solutions for exchange of health information. Certification of
> systems, conformance testing capabilities, and on-site verification of
> the accurate implementation of standards are all necessary components
> to enhance the capabilities of and achieve continued growth among
> interoperable networks. As interoperability standards and
> specifications are established and updated, methods to test and verify
> their implementation will be critical to ensure that exchange of
> health information seamlessly evolves. Strategy 1.2.5 seeks to promote
> the development of processes and infrastructure for testing and
> verifying that recognized data and technical standards and nationwide
> policies are being consistently implemented to ensure
> interoperability.*

**Strategy 1.2.6:** Encourage health care organizations to provide
personal health information in useable standardized electronic form to
consumers or their designees.

> *Consumers are being encouraged to take a more active role in managing
> their own health care. Interoperable health IT can catalyze
> patient-focused care by increasing consumers' (or their designees')
> ability to electronically access, accumulate, and manage their
> personal health information. Greater access to usable, electronic
> health information in standard formats can yield improvements in
> health literacy, patient-provider communication, care coordination,
> and overall quality of care. Strategy 1.2.6 seeks to encourage health
> care organizations to offer health information to consumers or their
> designees in standardized electronic form.*

**Strategy 1.2.7:** Increase the availability of health information
service providers that compete to support exchange of health
information.

> *The secure exchange of health information can be costly to support.
> With shared standards there are opportunities for health information
> service providers to support multiple organizations and markets
> helping to drive down the costs of exchange. Steady growth in the
> number of health information service providers must occur to maximize
> the ability of providers and patients to access and use electronic
> health information for care delivery. Currently, a number of different
> models for exchange of health information have emerged; however, most
> organizations still cannot exchange data with each other. Information
> service providers that adhere to recognized interoperability
> standards, specifications, and policies will be able to support an
> interoperable health information infrastructure nationwide.*

**Strategy 1.2.8:** Through the identification and recognition of
standards, empower individuals to use their health data to serve their
needs beyond direct patient care delivery.

> *Medical records play a significant role in many areas of an
> individual's life beyond direct patient care. Records are needed for
> everything from preventing illness, to establishing immunizations for
> school attendance, to determining the impact of a disabling condition
> in order to obtain services and benefits. Immediately critical in this
> arena is the need to enable persons with disabilities to authorize the
> electronic movement of their medical records to key public and private
> service providers. This strategy seeks to promote the development and
> recognition of standards necessary to support this type of
> interoperability, and to encourage providers to take advantage of the
> benefits it brings.*

**Recent Federal Government Progress**

Several federal agencies are involved in multiple initiatives that will
advance this objective. This work has at times been informed by certain
federal advisory body recommendations that were submitted to the
Secretary of HHS. Table 1.2 provides a list of these initiatives along
with the appendix page where a summary of each can be found. Activities
focus on three main areas: support of development of data and technology
exchange standards; pilot testing of standards; and adopting standards
within the federal government and promoting adoption within the private
sector.

+-----------------------------------------------------------------------+
| **Table 1.2 -- Current Health IT Initiatives and Federal Advisory     |
| Committees Addressing Objective 1.2**                                 |
+=======================================================================+
| **Federal Agency and Department Initiatives**                         |
+-----------------------------------------------------------------------+
| > **AHRQ:** Health IT Portfolio (Page A30), United States Health      |
| > Information Knowledgebase (USHIK: Page A31)                         |
+-----------------------------------------------------------------------+
| > **CMS:** ICD-10 (Page A36), Medicaid Information Technology         |
| > Architecture (MITA: Page A36), Medicaid Transformation Grants (Page |
| > A36), Beneficiary Information Services (Page A35)                   |
+-----------------------------------------------------------------------+
| > **FDA:** Structured Product Labeling for Products (Page A38)        |
+-----------------------------------------------------------------------+
| > **HRSA:** Health IT Electronic Health Record and Innovations Grants |
| > (Page A39), Telehealth Grants (Page A39), Regional Genetic and      |
| > Newborn Screening Service Collaboratives (Page A39)                 |
+-----------------------------------------------------------------------+
| > **IHS:** Resource and Patient Management System (Page A41)          |
+-----------------------------------------------------------------------+
| > **NIH:** Cancer Biomedical Informatics Grid (Page A42), Support,    |
| > Maintenance, & Dissemination of Standard Clinical Vocabularies      |
| > (Page A43)                                                          |
+-----------------------------------------------------------------------+
| > **ONC:** Planning for AHIC 2.0 (Page A48), Certification Commission |
| > for Healthcare Information Technology (CCHIT: Page A46), Federal    |
| > Interdepartmental Health IT Collaborative \[Multi-agency\] (Page    |
| > A46), Federal Health Architecture (FHA) \[Multi-agency\] (Page      |
| > A47), Healthcare Information Technology Standards Panel (HITSP:     |
| > Page A47), Nationwide Health Information Network (NHIN: Page A47),  |
| > Use Case Development (Page A49)                                     |
+-----------------------------------------------------------------------+
| > **HHS/OS:** Personalized Healthcare (Page A52), Value-driven Health |
| > Care (Page A53)                                                     |
+-----------------------------------------------------------------------+
| > **SAMHSA:** Health IT Initiatives (Page A54)                        |
+-----------------------------------------------------------------------+
| > **NIST:** Conformance Testing Infrastructure (Page A55); Security   |
| > Technology (Page A55)                                               |
+-----------------------------------------------------------------------+
| > **DoD:** AHLTA (Page A56), Memorandum of Agreement with State of    |
| > Florida (Page A56)                                                  |
+-----------------------------------------------------------------------+
| > **SSA:** Medical Evidence Request and Data Use Prototype (Page 59), |
| > NHIN "Release of Information to a Trusted Entity" Use Case Funding  |
| > and Participation (Page 59), Personal Health Record Prototype (Page |
| > 59)                                                                 |
+-----------------------------------------------------------------------+
| > **VA:** Personal Health Record (Page A57)                           |
+-----------------------------------------------------------------------+
| > **FCC:** Rural Health Care Pilot Program (Page A58)                 |
+-----------------------------------------------------------------------+
| **Inter-Departmental and Inter-Agency Initiatives**                   |
+-----------------------------------------------------------------------+
| > **AHRQ, FDA, NLM, NCI, and VA:** Data Standards Program (Page A59)  |
+-----------------------------------------------------------------------+
| > **DoD and VA:** Exchange of Information (FHIE, BHIE, CHDR, LDSI:    |
| > Page A60)                                                           |
+-----------------------------------------------------------------------+
| > **DoD and VA:** Joint EHR (Page A60)                                |
+-----------------------------------------------------------------------+
| **Federal Advisory Committees**                                       |
+-----------------------------------------------------------------------+
| > National Committee on Vital and Health Statistics (NCVHS: Page A62) |
+-----------------------------------------------------------------------+
| > American Health Information Community (AHIC: Page A63), with its    |
| > workgroups on Consumer Empowerment (Page A65), Electronic Health    |
| > Records (Page A65), Personalized Healthcare (Page A66)              |
+-----------------------------------------------------------------------+

\*\*\*\*

**[Objective 1.3]{.underline} *-- Adoption:* Promote the nationwide
adoption of interoperable electronic health records (EHRs) by providers,
and the adoption of personal health records (PHRs) and other consumer
health IT tools by consumers and their designees.**

> **Measure:** Percentage of physician offices using certified EHR
> systems.
>
> **Target:** 40% by 2012
>
> (This outcome targeted for 2012 is consistent with President Bush's
> target of the majority of Americans to have access to EHRs by 2014.)
>
> **Measure:** Percentage of small physician office practices (those
> with five physicians or fewer) using certified EHR systems.
>
> **Target:** 12% by 2012
>
> **Method:** Annual national survey of a scientific sample of physician
> offices.

**Discussion\
**Adoption of interoperable health information technology by providers
and patients and its subsequent routine use are the critical foundations
for transforming the current health care system to one that focuses on
the patient while providing quality in an efficient manner.

-   In its 2001 report - [Crossing the Quality Chasm: A New Health
    System for the 21st Century](http://www.iom.edu/?id=12736)[^2] --
    the Institute of Medicine describes *quality care* as safe, timely,
    effective, efficient, equitable, and patient-centric. The report
    documents how this might be achieved, including the critical
    importance of timely access by clinicians to accurate and
    comprehensive electronic health information about each of their
    patients.

> Adoption of interoperable electronic health records by clinicians
> throughout the delivery system can improve:

1.  Safety through provision of warnings and alerts when actions are
    taken that could injure a patient.

2.  Timeliness by fostering communications between providers and
    patients to assure that an individual's needs are understood prior
    to a scheduled encounter and appropriately met.

3.  Effectiveness by providing and assessing comprehensive information
    about a patient's care against evidence-based guidelines for care.

4.  Efficiency by presenting the comprehensive information necessary to
    coordinate care across multiple settings and providers, thus
    eliminating duplication and delays.

5.  Equity as these technologies are made widely available to all
    populations.

6.  Patient-centeredness by incorporating and presenting information
    about patient choices, preferences, and values in their clinical
    record[^3]^\*^.

-   Widespread adoption of health information technologies will also
    support more *cost efficient* care -- beyond the efficiencies gained
    from improvements in quality from enhanced patient safety, effective
    application of preventive processes, and better coordinated care.
    Through the use of health IT, more robust data will become available
    about variations in outcomes associated with different care
    processes. And, as therapies are tailored more specifically to each
    patient, the health system will become more cost-efficient by
    employing only those therapies known to be effective for that
    patient.

-   The health of individuals and of communities is not solely dependent
    on the health care delivery system. Individuals are in part
    responsible for their own health, and can affect it through the
    decisions they make regarding their lifestyle, dietary and exercise
    habits, accessing preventive health care services, and even pursuit
    of "good health" according to their own personal, basic beliefs.
    However, choices and beliefs will lead to better health only if a
    person is well-informed. Electronic access to one's own clinical
    information, the ability to communicate electronically with one's
    clinicians, the ability to ensure that medical information is
    available to key non-medical service providers, and the ability to
    access pertinent health information related to one's condition or
    situation are all critical to well-informed, timely, individual
    choice and engagement. Personal Health Records (PHRs) are products
    that can collect, collate, and present the comprehensive data needed
    by engaged, activated individuals and for tools that can reformat
    the data in a manner most useful for those individuals.

**Strategies**

Nine strategies, in addition to those related to privacy, security, and
interoperability, work together to achieve the objective of nationwide
adoption of EHRs, PHRs and other consumer health IT tools. The initial
five of these strategies (1.3.1 through 1.3.5) specifically address EHR
adoption in the health care delivery system and the President's goal of
making electronic health records available to most Americans by 2014.
Strategies 1.3.6 and 1.3.7 focus on the emerging areas of consumers'
access to, and use of, electronic health information related to their
own health and care. Strategies 1.3.8 and 1.3.9 are designed to advance
patient-focused health care by addressing liability, licensure, and
other issues that can promote the provision of care when the patient is
in a remote setting, not in the same physical setting as the clinician.
(Details in Appendix A beginning on Page A8.)

**Strategy 1.3.1:** Remove business barriers and disincentives for
provider and delivery system adoption of EHRs.

> *Evidence suggests that there are barriers to the adoption and use of
> EHRs, including the cost of the EHR, changes in workflow processes,
> and time and effort required for training. This strategy will promote
> adoption by working to remove business barriers and disincentives.*

**Strategy 1.3.2:** Increase the likelihood of efficient and effective
EHR purchase and implementation.

> *The EHR adoption process is complicated, time consuming, and has been
> shown to decrease productivity in the short term, before beneficial
> effects related to health care occur. Sufficient provider training and
> technical assistance can help health care providers navigate the
> adoption process so that they better understand the products and can
> purchase and implement the software successfully. In this way, the
> benefits of health IT will be realized more rapidly and the number of
> effective and efficient EHR implementations can be maximized.*

**Strategy 1.3.3:** Increase the value of EHRs through interoperability,
clinical decision support, and other technical advances.

> *Clinicians find value in products and services that decrease their
> administrative burden, increase their access to comprehensive
> information about a given patient, and present clinical information in
> a manner that enables accurate and timely diagnoses, treatments, and
> care. To the extent that EHRs have these features and these features
> work well, clinicians will be more inclined to invest in EHR products.
> This strategy addresses the technical and implementation challenges
> that must be overcome to assure routine inclusion and use of these
> features within EHRs.*

**Strategy 1.3.4:** Promote certified health IT products as critical
components and standards of clinical care.

> *The risk of purchasing a product that does not meet the provider's
> needs is one of the major barriers to widespread adoption of EHRs.
> Private sector certification processes would minimize this risk by
> assuring that the certified products meet specific criteria for
> functionality, security, and interoperability. As such, this process
> would not only protect the clinician purchaser, but would also allow
> the federal government, to the extent permitted by law to directly
> stimulate the adoption of interoperable products in both the public
> and private sectors through contractual mechanisms that reference use
> of certified systems.*

**Strategy 1.3.5:** Develop the workforce for health IT product
development and use.

> *Health IT development and implementation require an appropriately
> trained, highly-skilled workforce to play a wide range of specialized
> and essential supporting roles. Currently, the numbers of trained
> health IT professionals are only adequate to support the relatively
> low rate of health IT adoption. To enable the adoption rate to
> increase, and thus enable attainment of the 40 percent adoption
> objective by 2012 (and over 50 percent by 2014), the size of this
> trained health IT workforce will need to increase substantially.*

**Strategy 1.3.6:** Identify key PHR functions and features that will
allow individuals to link their health information to a wide variety of
market-driven personal health tools that they and their designees find
valuable in managing their heath and care.

> *PHRs have low rates of adoption to date for many reasons. While
> secure websites that enable patients to access their electronic health
> records are widely used where available, there is considerable
> confusion about what constitutes a free-standing PHR that is wholly
> controlled by the patient or consumer. This strategy seeks to define
> the key elements of a free standing PHR that will support secure
> maintenance of an individual's personal health information so that it
> can link to the myriad of applications being developed in the
> marketplace to support that individual's ability to manage his or her
> own health.*

**Strategy 1.3.7:** Design methods to promote the use of PHRs and other
consumer health IT tools by consumers and their designees.

> *Communicating with consumers about the benefits of PHRs and self
> management of one's own health may require new approaches to be
> effective. This strategy will expand and increase our understanding of
> how best to use these new technologies to the benefit of individuals
> interested in better management of their own health and care.*

**Strategy 1.3.8:** Minimize liability risks and clarify misperceptions
of liability risks for providers using health IT, while preserving or
enhancing patient protections.

> *Many providers are concerned about both real and perceived liability
> risks of using EHRs and participating in the exchange of electronic
> health information. This strategy will promote clinician adoption of
> health IT by addressing issues related to state-based licensure and
> certification criteria that can mitigate liability risk.*

**Strategy 1.3.9:** Remove technical, financial, workflow, and other
barriers to diagnosing, treating, and communicating with patients
outside the boundaries of traditional health care settings.

> *Our provider focused health care system is predicated on patients
> accessing care in the clinical setting.  However, actual care is
> primarily dependent on decisions made in the home, office, or school
> setting by the patient -- often without the guidance of their
> clinicians.  Adoption and use has been very slow of new technologies
> that can provide data and enable communication between individuals and
> their clinicians at the time when it is needed.  This strategy will
> promote adoption by helping the industry to understand the sources of
> the barriers to adoption and by identifying solutions that promote
> more widespread use of these technologies.*

**Recent Federal Government Progress**

Several federal agencies are involved in multiple initiatives that will
advance this objective. This work has at times been informed by certain
federal advisory body recommendations that were submitted to the
Secretary of HHS. Table 1.3 provides a list of these initiatives along
with the appendix page where a summary of each can be found.

+-----------------------------------------------------------------------+
| **Table 1.3 -- Current Health IT Initiatives and Federal Advisory     |
| Committees Addressing Objective 1.3**                                 |
+-----------------------------------------------------------------------+
| **Federal Agency and Department Initiatives**                         |
+-----------------------------------------------------------------------+
| > **AHRQ:** Health IT Portfolio (Page A30)                            |
+-----------------------------------------------------------------------+
| > **ASPE:** Health IT Activities (Page A32)                           |
+-----------------------------------------------------------------------+
| > **CMS:** EHR Adoption Demonstration (Page A35), E- Prescribing      |
| > Efforts (Page A35), ICD-10 (Page A36), Medicaid Information         |
| > Technology Architecture (MITA: Page A36), Medicaid Reimbursement    |
| > for Telehealth (Page A36), Medicaid Transformation Grants (Page     |
| > A36), Beneficiary Information Services (Page A35)                   |
+-----------------------------------------------------------------------+
| > **FDA:** Structured Product Labeling for Products (Page A38)        |
+-----------------------------------------------------------------------+
| > **HRSA:** Rural Hospital Flexibility Grant Program (FLEX: Page      |
| > A39), Health IT Electronic Health Record and Innovations Grants     |
| > (Page A39)                                                          |
+-----------------------------------------------------------------------+
| > **IHS:** Resource and Patient Management System (Page A41),         |
| > Telehealth (Page A41)                                               |
+-----------------------------------------------------------------------+
| > **NIH:** Cancer and Biomedical Informatics Grid (Page A42), Support |
| > for Biomedical Informatics Research Training (Page A43), Health     |
| > Informatics R & D (Page A43)                                        |
+-----------------------------------------------------------------------+
| > **OCR:** Health IT and Health Disparities/Special Needs Populations |
| > (Page A45)                                                          |
+-----------------------------------------------------------------------+
| > **ONC:** Certification Commission for Healthcare Information        |
| > Technology (CCHIT: Page A46), Secure Messaging Pilot (Page A48),    |
| > Standardized Measures for Adoption of EHRs (Page A48), Use Case     |
| > Development (Page A49)                                              |
+-----------------------------------------------------------------------+
| > **HHS/OS:** Personalized Healthcare (Page A53), Value-driven Health |
| > Care (Page A53)                                                     |
+-----------------------------------------------------------------------+
| > **SAMHSA:** Health IT Initiatives (Page A54)                        |
+-----------------------------------------------------------------------+
| > **DoD:** AHLTA (Page A56)                                           |
+-----------------------------------------------------------------------+
| > **VA:** Electronic Health Record (VistA, CPRS: Page A57),           |
| > Telehealth (Page 57), Personal Health Record (Page 57)              |
+-----------------------------------------------------------------------+
| **Inter-Departmental and Inter-Agency Initiatives**                   |
+-----------------------------------------------------------------------+
| > **DoD & VA:** Exchange of Information (FHIE, BHIE, CHDR, LDSI:Page  |
| > A60), Joint EHR (Page A60)                                          |
+-----------------------------------------------------------------------+
| > **OIG & CMS:** Hospital Donation of Health IT (Page A60)            |
+-----------------------------------------------------------------------+
| **Federal Advisory Committees**                                       |
+-----------------------------------------------------------------------+
| > American Health Information Community (AHIC: Page A63), with its    |
| > workgroups on Chronic Care (Page A64), Consumer Empowerment (Page   |
| > A65), Electronic Health Records (Page A65), Personalized Healthcare |
| > (Page A66)                                                          |
+-----------------------------------------------------------------------+

**\*\*\*\***

**[Objective 1.4]{.underline} *- Collaborative Governance:* Establish
mechanisms for equitable and balanced multi-stakeholder priority-setting
and decision-making to achieve a secure, nationwide, interoperable
health information technology architecture.**

> **Measure:** Achievement of a self-sustaining AHIC Successor that will
> have broad representation from public and private sectors and provide
> coordination and continued development of electronic exchange of
> health information across the country by 2011
>
> **Target:** Successor will have balanced public and private
> stakeholder representation and be self-sustaining
>
> **Methods:** Financial reports of the AHIC Successor and review of
> board composition for adequacy of representation

**Discussion**

Ensuring a mechanism for collaborative governance involving all major
stakeholder groups across the public and private sectors will advance
the necessary planning, priority-setting, consistent approaches to
implementing policies, and consensus building needed to achieve
interoperable exchange of health information and, in turn, support the
overall transformation of care.

-   Governance of the exchange of health information supported by
    entities with *equitable and balanced multi-stakeholder*
    representation, will create forums for all interested parties to
    come together to voice their interests and priorities and develop
    coordinated solutions to realize interoperability across the health
    care system. Progress toward the goal of widespread adoption of
    interoperable health IT requires support from all health care
    stakeholders, as well as their participation in *priority-setting
    and decision-making*. Governance entities at regional, state, and
    national levels facilitate discussion and common solution
    development toward evolving necessary policies, standards, and
    infrastructure to support health care transformation. Lack of
    support from any major stakeholder group could lead to solutions
    that work for some and not others, or halt progress toward the goal
    altogether.

```{=html}
<!-- -->
```
-   *Multi-stakeholder* governance entities can bridge efforts across
    the public and private sectors and geographies to ensure coordinated
    progress towards an electronically connected, patient-focused health
    care system.

-   Consumer representation in these multi-stakeholder entities will
    support development of a transformed health care delivery system
    that is patient-focused, with the exchange of health information
    consumer-controlled.

**Strategies**

Three strategies will enable equitable and balanced public-private
governance for the electronic exchange of health information that will
transform health care and engage governmental participation at the
federal, state, local, and tribal levels. (Details in Appendix A
beginning on Page A12.)

**Strategy 1.4.1:** Establish a national public-private governance
entity to advance interoperability and sustainable exchange of health
information nationwide.

> *Sustainable exchange of health information will require broad
> inclusion and buy-in from all of the nation's health care
> stakeholders. The priorities and activities surrounding this exchange
> must be defined and governed by an objective, equitable, broadly
> representative and transparent entity. While this strategy recognizes
> the exchange of health information for care delivery as the first
> priority for widespread adoption, it also acknowledges that in order
> to enable most quality improvements and efficiency gains, these care
> delivery requirements must be coordinated with those necessary to meet
> population health needs. Strategy 1.4.1 also involves mechanisms to
> ensure accountability of governance entities across geographies that
> will reinforce responsible policies and procedures for appropriate use
> and exchange of electronic health information.*

**Strategy 1.4.2:** Empower consumers through representation in
multi-stakeholder governance entities at the national, state, and local
level.

> *For care delivery to truly be patient-focused, consumers' interests
> must be reflected in policies and governance for the exchange of
> health information nationwide. Consumer participation in national,
> state, and local governance entities is necessary to enable health IT
> initiatives that reflect consumer priorities, ensure public trust, and
> maximize consumer welfare. Strategy 1.4.2 emphasizes the importance of
> consumer involvement in developing organizational policies and
> procedures around the exchange of health information, identifying
> effective methods for engaging consumers, and working to promote
> consumer involvement in activities nationwide.*

**Strategy 1.4.3:** Promote participation by federal, state, local, and
tribal government representatives in multi-stakeholder governance
entities for the exchange of health information, at all appropriate
levels: national, state, and local.

> *Communication and aligned priorities regarding the use and exchange
> of health information at varying levels of jurisdiction must exist to
> achieve the care transformation that the exchange of health
> information can bring. This strategy recognizes the need to promote
> shared and complementary participation in governance activities and to
> align goals and organizational policies and practices for the exchange
> of electronic health information across all geographic levels
> nationwide. It is also designed to support regular and organized
> interaction, collaboration, communication, and participation by
> federal, state, local, and tribal government representatives in such
> activities.*

**Recent Federal Government Progress**

Several federal agencies are involved in multiple initiatives that will
advance this objective. This work has at times been informed by certain
federal advisory body recommendations that were submitted to the
Secretary of HHS. Table 1.4 provides a list of these initiatives along
with the appendix page where a summary of each can be found. The
majority of these activities focus on fostering coordination and
building consensus among a broad range of health IT stakeholders on
topics including federal health IT policy and decision-making,
differences in state policy, how to advance consistent policies for
organizations engaged in the exchange of health information, and
consistent health IT terminologies and definitions. The American Health
Information Community (AHIC) has had a very prominent role since its
creation, advising the Secretary of HHS regarding health IT coordination
and collaboration across the public and private sectors.

+-----------------------------------------------------------------------+
| **Table 1.4 -- Current Health IT Initiatives and Federal Advisory     |
| Committees Addressing Objective 1.4**                                 |
+-----------------------------------------------------------------------+
| **Federal Agency and Department Initiatives**                         |
+-----------------------------------------------------------------------+
| > **AHRQ:** Health IT Portfolio (Page A30)                            |
+-----------------------------------------------------------------------+
| > **NIH:** Cancer and Biomedical Informatics Grid (Page A42),         |
| > Clinical Translational Science Awards (Page A42)                    |
+-----------------------------------------------------------------------+
| > **OCR:** Health IT and Health Disparities/Special Needs Populations |
| > (Page A45)                                                          |
+-----------------------------------------------------------------------+
| > **ONC:** Certification Commission for Healthcare Information        |
| > Technology (CCHIT: Page A46), Federal Interdepartmental Health IT   |
| > Collaborative \[Multi-agency\] (Page A46), Federal Health           |
| > Architecture (FHA) \[Multi-agency\] (Page A47), Federal Interagency |
| > Health IT Policy Council \[Multi-agency\] (Page A47), Planning for  |
| > AHIC 2.0 (Page A48),State Alliance for e-Health (Page A48), State   |
| > Level Health Information Exchange Consensus Project (Page A49),     |
| > Terminology Consensus Project (Page A49)                            |
+-----------------------------------------------------------------------+
| **Federal Advisory Committees**                                       |
+-----------------------------------------------------------------------+
| > National Committee on Vital and Health Statistics (NCVHS: Page A62) |
+-----------------------------------------------------------------------+
| > American Health Information Community (AHIC: Page A63), with its    |
| > workgroups on Population Health and Clinical Care Connections (Page |
| > A66), and Quality (Page A67)                                        |
+-----------------------------------------------------------------------+

**Goal Two -- *Improve Population Health***

**Enable the appropriate, authorized, and timely access and use of
electronic health information to benefit public health, biomedical
research, quality improvement, and emergency preparedness.**

Goal Two of the Plan concentrates on enabling the use of electronic
health information for critical health improvement activities that
promote the health of communities and the population as a whole
nationwide. Goal Two envisions the use of interoperable health IT to
develop more robust and effective systems for such activities as disease
detection and the mobilization of resources to manage outbreaks,
generating new knowledge from clinical studies, identifying health care
practices associated with best outcomes, and helping communities manage
and recover from natural disasters.

Because of their focus on communities and populations, the activities
under this second goal differ fundamentally from those of the first goal
that focus on the care of individuals. In general, the activities under
Goal One anticipate access and use of information about one person at
any given time; activities under Goal Two anticipate analysis of
information that is frequently combined use for the public good.

The Plan articulates four objectives that support achievement of this
goal. The themes of privacy and security, interoperability, adoption,
and collaborative governance recur to describe the objectives in Goal
Two, but will be seen as well in the descriptions of the objectives; the
objectives themselves and the proposed strategies to achieve them are
targeted specifically to population health. In their simplified form the
objectives are:

> ***Objective 2.1 -- Privacy and Security:*** Advance privacy and
> security policies, principles, procedures, and protections for health
> information access and use in population health
>
> ***Objective 2.2 -- Interoperability:*** Enable the mobility of health
> information to support population-oriented uses
>
> **Objective 2.3 -- *Adoption:*** Promote nationwide adoption of
> technologies and technical functions that will improve population and
> individual health
>
> **Objective 2.4 -- *Collaborative Governance:*** Establish coordinated
> organizational processes supporting information use for population
> health

**[Objective 2.1]{.underline} -- *Privacy and Security:* Advance the
development of privacy and security policies, principles, procedures,
and protections that facilitate appropriate access to, or transfer and
use of, electronic health information for public health, biomedical
research, quality improvement, and emergency preparedness.**

> **Measure:** Federal agencies involved in the electronic exchange of
> health information and charged with population health activities
> adhere to principles for exchanging electronic health information in a
> manner consistent with a nationwide confidentiality, privacy, and
> security framework by 2012.

**Target:** 80% of agencies by 2012.

> **Method:** Annual survey of federal agencies charged with population
> health activities.

**Discussion**

A nationwide, interoperable health IT architecture in the United States
must be multi-functional and dynamic -- supporting not only the needs of
the health care delivery system, but also population health activities.
While it is essential that health information be accurate and accessible
for this wide-range of health information uses, it is critical that
appropriate policies be in place to protect patient confidentiality and
privacy when health information is used for purposes outside of direct
patient care. Objective 2.1 seeks to advance development of privacy and
security policies that protect access to health information in an
interoperable electronic environment, in a manner that the public
trusts, and through a coordinated effort that engages all stakeholders
at the federal, state, local and tribal levels.

-   Identifying or establishing policies, principles, procedures, and
    protections that set parameters on when data may be accessed, by
    whom, and for what purposes can promote *appropriate and authorized
    access and use* of electronic health information for population
    health purposes. Coming to nationwide consensus principles on health
    information security, stewardship, and access for each of the
    population health activities -- because each has unique data needs
    -- will engender trust among all stakeholders that the information
    is accurate and confidential.

-   Facilitating the exchange of population health data by harmonizing
    privacy and security policies across jurisdictions can enable the
    *timely access and use* of electronic health information for
    population health purposes. By increasing harmonization of the
    privacy and security requirements that are limiting -- or are
    perceived as limiting -- information flow within and across state
    lines, or between states and the federal government, users of
    population health information can receive data in a more timely
    fashion, allowing them to more accurately assess public
    health/epidemiologic risks, report physician feedback on quality
    measures, or deploy medical supplies and staff in an emergency.

**Strategies**

Four strategies work in combination to achieve this objective. (Details
in Appendix A beginning on Page A14.)

**Strategy 2.1.1:** Employ the confidentiality, privacy, and security
framework (see Strategy 1.1.1) for policy development to establish
patient and consumer trust and advance the exchange of electronic health
information for population health purposes.

> *Privacy and security policies currently differ at the federal and
> state level, across states, across organizations, and among distinct
> stakeholders and users of data. This strategy can help guide
> organizations in developing confidentiality, privacy, and security
> policies that enable appropriate access to, and use of, electronic
> exchange of health information for population health purposes such as
> public health, biomedical research, quality improvement, and emergency
> preparedness. Building from [HIPAA](http://www.hhs.gov/ocr/hipaa/) and
> other existing federal privacy and security laws such as the Privacy
> Act and the Federal Information Security Management Act, this
> framework will take into account the information needs for the range
> of population health activities, as well as the need to engender
> consumer trust that information will be kept private and secure.*

**Strategy 2.1.2:** Identify and evaluate federal statutes or
regulations that conflict or are inconsistent -- or are perceived to
conflict or be inconsistent -- with the exchange of electronic health
information used for population health purposes, while preserving or
enhancing patient protections.

> *Some federal statutes and regulations related to the disclosure of
> health information for population health uses were written before
> interoperable health IT and widespread exchange of electronic health
> information became feasible and were considered, and, therefore, may
> inadvertently and unnecessarily prohibit or limit the appropriate
> exchange of such information -- or be perceived to do so. This
> strategy seeks to increase appropriate and timely access to health
> information across various population health uses, while maintaining
> an appropriate level of privacy and security, by clarifying the
> current policies for all users in the context of interoperable health
> IT.*

**Strategy 2.1.3:** Facilitate state-based activities to identify and
address challenges to the use of health IT and the intra- and
inter-state exchange of electronic health information to support
population health, while preserving or enhancing the current level of
patient protections.

> *Many state laws that address privacy or the disclosure of electronic
> health information were written before interoperable health
> information technology and the widespread exchange of electronic
> health information became feasible. The federal government will
> promote collaboration and coordination among stakeholders at the state
> level to advance the electronic exchange of health information for
> population health while ensuring proper patient privacy and security
> protections.*

**Strategy 2.1.4:** Increase stakeholder understanding of current
federal health privacy and security laws in order to promote trust in
the use of health IT and exchange of electronic health information for
population health purposes.

> *All stakeholders involved in exchange of electronic health
> information for population health purposes -- including consumers --
> should have an understanding of federal privacy and security policies
> to enable appropriate and timely access and use of health information
> for population health activities.*

**Recent Federal Government Progress**

Several federal agencies are involved in multiple initiatives that will
advance this objective. This work has at times been informed by certain
federal advisory body recommendations that were submitted to the
Secretary of HHS. Table 2.1 provides a list of these initiatives along
with the appendix page where a summary of each can be found. Activities
focus on offering guidance and clarifications to ensure privacy and
security protections are maintained or enhanced in electronic health
information access and exchange policies related to population health
activities. They also focus on how the array of privacy and security
standards, policies, and practices across jurisdictions can support
authorized population health uses.

+-----------------------------------------------------------------------+
| **Table 2.1 -- Current Health IT Initiatives and Federal Advisory     |
| Committees Addressing Objective 2.1**                                 |
+-----------------------------------------------------------------------+
| **Federal Agency and Department Initiatives**                         |
+-----------------------------------------------------------------------+
| > **AHRQ:** Health IT Portfolio (Page A30)                            |
+-----------------------------------------------------------------------+
| > **CMS:** HIPAA Security Rule (Page A35)                             |
+-----------------------------------------------------------------------+
| > **NIH:** Genome Wide Association Studies Data Sharing Policy (Page  |
| > A42)                                                                |
+-----------------------------------------------------------------------+
| > **NIST:** Security Technology (Page A55)                            |
+-----------------------------------------------------------------------+
| > **OCR:** HIPAA Privacy Rule and Health IT (Page A45)                |
+-----------------------------------------------------------------------+
| > **ONC:** Health Information Security and Privacy Collaborative      |
| > (HISPC: Page A47), Healthcare Information Technology Standards      |
| > Panel (HITSP: Page A47), Nationwide Health Information Network      |
| > (NHIN: Page A47), State Alliance for e-Health (Page A48)            |
+-----------------------------------------------------------------------+
| > **HHS/OS:** Personalized Healthcare (Page A52)                      |
+-----------------------------------------------------------------------+
| > **SAMHSA:** Health IT Initiatives (Page A54)                        |
+-----------------------------------------------------------------------+
| **Federal Advisory Committees**                                       |
+-----------------------------------------------------------------------+
| > National Committee on Vital and Health Statistics (NCVHS: Page A62) |
+-----------------------------------------------------------------------+
| > American Health Information Community (AHIC: Page A63), with its    |
| > workgroup on Confidentiality, Privacy, and Security (Page A64)      |
+-----------------------------------------------------------------------+

\*\*\*\*

**[Objective 2.2]{.underline} -- *Interoperability:* Enable the secure
exchange of interoperable health information among health-related
organizations -- as well as providers, patients and their designees --
to support appropriate population-oriented uses.**

> **Measure:** Percentage of population health agencies -- in the public
> sector at the federal, state and local levels as well as the private
> sector -- that use recognized interoperability standards and NHIN
> specifications for exchanging health information. (Developmental.)
>
> **Target:** To be determined, pending review of baseline data
> collected in 2010.
>
> **Method**: Survey of selected samples of agencies or results of
> automated conformance testing.

**Discussion**

Public health, biomedical research, quality improvement, and emergency
preparedness efforts currently operate in a constrained environment that
is largely paper-based, poorly coordinated and inefficient. As
electronic health information becomes more robust and more widely
available, those engaged in population health activities increasingly
see it as a critical resource. The advancement of recognized
interoperability standards, policies, and approaches -- consistent with
those used to support the exchange of health information for direct
patient care -- can also promote the interoperability of health IT
solutions and networks necessary to enable the exchange of health
information for population-oriented uses.

-   Implementing recognized interoperability standards and policies can
    promote *timely access and use* of electronic health information for
    population health purposes. Exchange of electronic health
    information among such diverse organizations and models requires
    interoperability standards that are specific and verifiable, and
    architecture to meet technical demands. The same standards should be
    used to exchange information among organizations involved in
    providing clinical care as those organizations that use the
    information for population purposes. Doing so will further enable
    such organizations to achieve their population health goals. At
    times, a higher degree of interoperability will be necessary for
    these purposes since the comparability, not just exchange of data,
    is critical to ensure that data can be merged from and used by
    diverse organizations.

-   There are several models for the exchange of health information
    including: organizationally based (e.g., integrated delivery
    networks), geographically-based (local, regional, and state-level
    entities and regional health information organizations), and
    personally controlled ("health data banks"). Promoting certification
    criteria for these organizations which address issues relating to
    *appropriate* access will help ensure *authorized* uses of health
    information for population health activities. To garner public trust
    for the use of health information for population health purposes,
    organizations that exchange health information and other data
    stewards should have to adhere to interoperability standards and
    employ common policies for collecting, storing, analyzing, and
    transmitting health information. Certification for organizations
    that exchange health information will promote implementation of and
    compliance with standards and policies on privacy and security, and
    data use and availability.

**Strategies**

Five strategies work in combination to achieve the objective of enabling
the secure exchange of interoperable health information for population
health purposes. (Details in Appendix A beginning on Page A17.)

**Strategy 2.2.1:** Advance the availability and use of consistent data
and technical standards that enable the merging of comparable data
originating from multiple organizations and sources in support of
population health uses.

> *Clinical, regional, state, and federal initiatives that promote and
> protect population health rely on access to aggregate health data from
> multiple sources. The wide array of organizations and their varying
> uses for the data has resulted in the emergence of different and often
> inconsistent data and technical standards. This strategy is critical
> to reducing the variation in data and technical standards and to
> promoting the utility of health information for population health
> purposes. It seeks to ensure that population health data users (public
> health, biomedical research, quality improvement and emergency
> preparedness activities) can use comparable information from different
> sources. It will also advance EHR functionality and interoperability
> to include standards, technical architecture, and certification
> requirements that support data sharing and use for population health
> purposes.*

**Strategy 2.2.2:** Allow for flexibility in the models for the exchange
of health information (organizational, geographic, and personally
controlled), while still advancing the specific standards and policies
necessary to ensure that they all work together to meet population
health needs.

> *Just as a number of different models for exchanging health
> information have emerged, these entities employ an array of technical
> architectures, network services, and policies to satisfy their unique
> priorities. Consistent standards that support exchange of electronic
> health information are critical to enabling timely access to and use
> of population health data. This strategy supports the continued
> evolution of different models and promotes innovation in developing
> new capabilities and services. It simultaneously ensures that emerging
> technical standards support the minimal set of services and policies
> needed to support population health initiatives. This strategy also
> seeks to foster the consideration of population health needs as a
> critical component of the development of these entities.*

**Strategy 2.2.3:** Assess the implementation of recognized standards
and nationwide policies in entities that exchange health information.

> *Testing and verification of the accurate implementation and use of
> data and technical standards is critical to increasing the
> interoperability of solutions for the exchange of health information.
> Certification of systems, conformance testing capabilities, and
> on-site verification of the accurate implementation of recognized
> standards and nationwide policies are all necessary components to
> enhance the capabilities of and achieve continued growth among
> interoperable networks. This strategy is critical to ensuring that
> organizations are employing the necessary standards and policies to
> assure secure and appropriate exchange of health information. It seeks
> to make certain that the population health capabilities of
> interoperable networks continue to evolve such that population health
> users may access and use data in a timely manner.*

**Strategy 2.2.4:** Promote the availability of health information in a
useable electronic form for appropriate population health users outside
of direct patient care.

> *Public health, biomedical research, quality improvement, and
> emergency preparedness activities each have their own distinct
> population health information needs. This strategy seeks to ensure
> that interoperable health information networks continue to meet this
> range of population health information uses and needs. It will promote
> timely access to useable electronic health information through
> interoperable health information networks that use recognized
> interoperability standards and the specifications developed through
> the NHIN initiative.*

**Strategy 2.2.5:** Advance the availability of needed clinical and
resource information for providers and emergency response teams when
responding to significant events that affect population health.

> *Health IT and networks for the exchange of health information, such
> as the networks that comprise the NHIN, can connect all members of
> emergency response teams -- from the top levels of the federal
> government to the providers in the field -- and enable timely access
> to comprehensive data. Building on the National Strategy for Public
> Health and Medical Preparedness established by the recent Homeland
> Security Presidential Directive, this strategy will ensure that the
> NHIN can support emergency response needs.*

**Recent Federal Government Progress**

Several federal agencies are involved in multiple initiatives that will
advance this objective. This work has at times been informed by certain
federal advisory body recommendations that were submitted to the
Secretary of HHS. Table 2.2 provides a list of these initiatives along
with the appendix page where a summary of each can be found. Activities
focus on development of nomenclature, content, and standards in support
of electronic exchange of health information for population health
purposes and on testing and adoption of these standards both within the
federal government and in collaboration with the public and private
sector.

+-----------------------------------------------------------------------+
| **Table 2.2 -- Current Health IT Initiatives and Federal Advisory     |
| Committees Addressing Objective 2.2**                                 |
+=======================================================================+
| **Federal Agency and Department Initiatives**                         |
+-----------------------------------------------------------------------+
| > **AHRQ:** Health IT Portfolio (Page A30), United States Health      |
| > Information Knowledgebase (USHIK: Page A31)                         |
+-----------------------------------------------------------------------+
| > **ASPR:** Homeland Security Presidential Directive 21 (Page A32),   |
| > Pandemic All-Hazards Preparedness Act (PAHPA: Page A33)             |
+-----------------------------------------------------------------------+
| > **CDC:** BioSense (Page A33), EPI-X (Page A33), National Healthcare |
| > Safety Network (Page A34), Public Health Information Network (Page  |
| > A34), Public Health Preparedness Systems (Page A34)                 |
+-----------------------------------------------------------------------+
| > **CMS:** Medicaid Information Technology Architecture (MITA: Page   |
| > A36), Medicaid Transformation Grants (Page A36)                     |
+-----------------------------------------------------------------------+
| > **FDA:** Sentinel Network (Page A38), Structured Product Labeling   |
| > for Products (Page A38)                                             |
+-----------------------------------------------------------------------+
| > **HRSA:** *Connections* Project (Page A38)                          |
+-----------------------------------------------------------------------+
| > **IHS:** National Data Repository (Page A40), Resource and Patient  |
| > Management System (Page A41)                                        |
+-----------------------------------------------------------------------+
| > **NIH:** Cancer Biomedical Informatics Grid (caBIG: Page A42),      |
| > Health Informatics R & D (Page A43), National Network of Libraries  |
| > of Medicine (Page A43), Support, Maintenance, & Dissemination of    |
| > Standard Clinical Vocabularies (Page A43)                           |
+-----------------------------------------------------------------------+
| > **ONC:** Certification Commission for Healthcare Information        |
| > Technology (CCHIT: Page A46), Federal Interdepartmental Health IT   |
| > Collaborative \[Multi-agency\] (Page A46), Federal Health           |
| > Architecture (FHA) \[Multi-agency\] (Page A47), Healthcare          |
| > Information Technology Standards Panel (HITSP: Page A47),           |
| > Nationwide Health Information Network (NHIN: Page A47), Planning    |
| > for AHIC 2.0 (Page A48),Use Case Development (Page A49)             |
+-----------------------------------------------------------------------+
| > **HHS/OS:** Personalized Healthcare (Page A52), Value-driven Health |
| > Care (Page A53)                                                     |
+-----------------------------------------------------------------------+
| > **SAMHSA:** Health IT Initiatives (Page A54)                        |
+-----------------------------------------------------------------------+
| > **NIST:** Conformance Testing Infrastructure (Page A55); Security   |
| > Technology (Page A55)                                               |
+-----------------------------------------------------------------------+
| > **DoD:** AHLTA (Page A56), Memorandum of Agreement with State of    |
| > Florida (Page A56)                                                  |
+-----------------------------------------------------------------------+
| > **FCC:** Rural Health Care Pilot Program (Page A58)                 |
+-----------------------------------------------------------------------+
| **Inter-Departmental and Inter-Agency Initiatives**                   |
+-----------------------------------------------------------------------+
| > **AHRQ, FDA, NLM, NCI, and VA:** Data Standards Program (Page A59)  |
+-----------------------------------------------------------------------+
| > **DoD and VA:** Exchange of Information (FHIE, BHIE, CHDR, LDSI:    |
| > Page A60), Joint EHR (Page A61)                                     |
+-----------------------------------------------------------------------+
| **Federal Advisory Committees**                                       |
+-----------------------------------------------------------------------+
| > National Committee on Vital and Health Statistics (NCVHS: Page A62) |
+-----------------------------------------------------------------------+
| > American Health Information Community (AHIC: Page A63), with its    |
| > workgroups on Consumer Empowerment (Page A65), Electronic Health    |
| > Records (Page A65), Personalized Healthcare (Page A66), Population  |
| > Health and Clinical Care Connections (Page A67), Quality (Page A67) |
+-----------------------------------------------------------------------+

> \*\*\*\*

**[Objective 2.3]{.underline} *-- Adoption:* Promote the nationwide
adoption of information technologies that enable the reliable and
efficient exchange of electronic health information to continuously
improve population health activities and individual health care
services.**

> **Measure:** Increase the electronic health information transmitted
> for population health use by ambulatory and inpatient providers that
> is re-use of information routinely collected in the course of patient
> care without re-entry or other manual intervention. (Developmental.)
>
> **Target:** To be determined, pending review of baseline data
> collected in 2010.
>
> **Method:** Survey of representative samples of population health
> agencies

**Discussion**

Improvements and advances in population health and individual health
care services depend on the ability to transmit electronic health
information efficiently and securely among data sources and data users.
Information can flow in both directions: "upstream" from providers and
consumers to authorized population health agencies, and "downstream"
from population health agencies to providers, consumers, and their
communities. Patients, providers, community agencies, and population
health agencies have distinct information to offer one another to serve
a wide range of useful purposes.

The increasing availability of individual patient data in electronic
form creates enormous potential for enhancing public health, clinical
research, heath care quality studies, and emergency preparedness. With
appropriate protections of security and privacy, information can flow
from practice-based or other local systems to population health agencies
and be immediately available for analysis. During disease outbreaks or
natural disasters, this information can promote all important
"situational awareness" that can save lives and make best use of the
available resources.

Reporting of patient-specific data for population health purposes --
such as disease surveillance, clinical research, or quality studies --
can be improved with the adoption of health IT functionalities and
standards which will support 'real-time' transmission of data. The
adoption of technologies and tools that streamline and automate the
information flow is an essential step in realizing the full potential of
population health through health IT.

**Strategies**

Three strategies work together to achieve Objective 2.3 of establishing
an efficient exchange of information among relevant entities to improve
population health activities and individual health care services.
(Details in Appendix A beginning on Page A19.)

**Strategy 2.3.1:** Establish mechanisms to optimize the exchange of
information between care providers using EHRs and authorized users of
population health data, as well as among authorized users and recipients
of population health data.

> *Health IT and information exchange can facilitate greater access to
> and use of population health data for all authorized users. This
> strategy seeks to enable the efficient transmittal of information
> between EHRs and authorized population health data users, and ensure
> timely and secure mechanisms for the exchange.*

**Strategy 2.3.2:** Minimize burden on health care providers when
reporting clinical data for population health purposes using EHRs and
other health IT, while ensuring consistent health information
protections.

> *The increased burden associated with providing clinical data for
> population health uses may limit participation by providers and other
> data sources in the exchange of health information. This strategy aims
> to reduce the burden on the delivery system and increase participation
> by promoting efficient data collection and reporting and facilitating
> the automated collection of population health data and use of
> non-clinical data sources.*

**Strategy 2.3.3:** Establish mechanisms for the electronic exchange of
health information among authorized users of population health data,
communities, and individual consumers.

> *This strategy supports the collection of appropriate information
> directly from consumers as well as community sources, with appropriate
> privacy protections in place, and the secure transmission of this
> information to population health agencies that are authorized to
> receive it. It also embraces dissemination of population health
> findings from population health agencies to consumers and communities.
> This mode of information exchange, which connects consumers to
> population health information without intermediation by health care
> providers, poses unique challenges that need to be examined and
> resolved, but the potential benefits are significant.*

**Recent Federal Government Progress**

Several federal agencies are involved in multiple initiatives that will
advance this objective. This work has at times been informed by certain
federal advisory body recommendations that were submitted to the
Secretary of HHS. Table 2.3 provides a list of these initiatives along
with the appendix page where a summary of each can be found. Activities
across the government include deployment of systems, infrastructure, and
policies that enable secure adoption, use and integration of population
based exchange of health information.

+-----------------------------------------------------------------------+
| **Table 2.3 -- Current Health IT Initiatives and Federal Advisory     |
| Committees Addressing Objective 2.3**                                 |
+-----------------------------------------------------------------------+
| **Federal Agency and Department Initiatives**                         |
+-----------------------------------------------------------------------+
| > **AHRQ:** Health IT Portfolio (Page A30)                            |
+-----------------------------------------------------------------------+
| > **ASPR:** Homeland Security Presidential Directive 21 (Page A32),   |
| > Pandemic All-Hazards Preparedness Act (PAHPA: Page A33)             |
+-----------------------------------------------------------------------+
| > **CDC:** BioSense (Page A33), Public Health Information Network     |
| > (Page A34)                                                          |
+-----------------------------------------------------------------------+
| > **CMS:** ICD-10 (Page A36), Medicaid Information Technology         |
| > Architecture (MITA: Page A36)                                       |
+-----------------------------------------------------------------------+
| > **FDA:** Sentinel Network (Page A38), Structured Product Labeling   |
| > for Products (Page A38)                                             |
+-----------------------------------------------------------------------+
| > **IHS:** National Data Repository (Page A40)                        |
+-----------------------------------------------------------------------+
| > **NIH:** Health Informatics R & D (Page A43), Clinical              |
| > Translational Science Awards (Page A42), Support, Maintenance, &    |
| > Dissemination of Standard Clinical Vocabularies (Page A43)          |
+-----------------------------------------------------------------------+
| > **ONC:** Use Case Development (Page A49)                            |
+-----------------------------------------------------------------------+
| > **HHS/OS:** Personalized Healthcare (Page A52), Value-driven Health |
| > Care (Page A53)                                                     |
+-----------------------------------------------------------------------+
| > **SAMHSA:** Health IT Initiatives (Page A54)                        |
+-----------------------------------------------------------------------+
| > **DoD:** AHLTA (Page A56)                                           |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Federal Advisory Committees**                                       |
+-----------------------------------------------------------------------+
| > American Health Information Community (AHIC: Page A63), with its    |
| > workgroups on Chronic Care (Page A65), Consumer Empowerment (Page   |
| > A65), Electronic Health Records (Page A65), Personalized Healthcare |
| > (Page A66)                                                          |
+-----------------------------------------------------------------------+

\*\*\*\*

**[Objective 2.4]{.underline} *-- Collaborative Governance*: Establish
coordinated and effective organizational processes---at the federal,
state, local. and tribal levels---to promote the availability and
management of aggregated clinical information to benefit population
health.**

> **Measure:** Percentage of governance entities with responsibility
> related to the exchange and use of information for population health
> that comply with consensus-based policies and processes.
> (Developmental.)
>
> **Target:** To be determined, pending review of baseline data
> collected in 2010.
>
> **Method:** Survey of governance entities or results of accreditation
> process if one is in place.

**Discussion**

Interoperable exchange of health information enables access to
electronic health information for population health uses: public health,
biomedical research, quality improvement and emergency preparedness.
Numerous needs for population health information exist across all levels
of government and in the private sector. Each type of use has unique
considerations, requiring tailored mechanisms and organizational
policies and practices to aggregate and share electronic health data.
Accountability mechanisms are needed to ensure that organizational
policies and processes across organizations overseeing the exchange of
health information protect consumers while meeting public health needs
and goals. Appropriate organization policies and processes, consistent
with nationwide policies, will facilitate the building of a common
information exchange infrastructure and ensure that all stakeholders
participate in and benefit from the exchange of health information for
various purposes.

-   Coordination of data capture and aggregation across federal, state,
    local, and tribal levels is critical to ensure the *timely access
    and use* of electronic health information for population health
    purposes.

-   Collaborative governance entities at regional, state, and national
    levels will directly engage a wide-range of agencies and other
    stakeholders to establish policies and processes for the appropriate
    use of data for population health. While federal agencies directly
    responsible for public health, biomedical research, quality
    improvement and emergency preparedness must determine how to use IT
    to support their missions, collaborative governance involving the
    public and private sectors will ensure *appropriate and authorized
    access and use* of data from the exchange of health information for
    population health purposes.

**Strategies**

Six strategies combine to achieve Objective 2.4 of facilitating
governance and coordination of the availability and management of
electronic health information for population health purposes. (Details
in Appendix A beginning on Page A21.)

**Strategy 2.4.1:** Establish and monitor the use of data stewardship
models that allow for capture and consistent use of electronic health
data for population health purposes through common practices compliant
with laws and organizational policies.

> *Appropriate data stewardship within existing laws and organizational
> policies is necessary to make needed data available to authorized
> population health users. This strategy works to establish a foundation
> of policies and procedures to ensure authorized and appropriate use of
> electronic health information for public health, biomedical research,
> quality improvement, and emergency preparedness. This foundation will
> facilitate a consistent approach to data stewardship across
> initiatives for the exchange of health information that are also
> involved with data aggregation and sharing for population health
> purposes.*

**Strategy 2.4.2:** In concert with federal partners, identify and
coordinate priorities, policies, and practices that are needed to
develop and implement quality measures in ways that are compatible with
different models for the exchange of health information.* *

> *There are unique concerns related to the collection and aggregation
> of electronic health information for defining and evaluating quality
> of care. This strategy supports the effective use of electronic health
> data by facilitating standardized data elements aligned across
> multiple stakeholders' quality measurement initiatives and promotes
> the use of an automated common set of electronic data elements. The
> use of this common data set will facilitate collection and aggregation
> of electronic health data that forms more complex and complete data
> resources for quality measurement.*

**Strategy 2.4.3:** Identify mechanisms, policies, and practices needed
to connect clinical care and public health for public health purposes,
including biosurveillance and emergency preparedness.

> *The exchange of electronic health information can support public
> health data needs at the federal, state, local, and tribal levels.
> This strategy will facilitate increased use of automated electronic
> health information for public health, biosurveillance, and emergency
> preparedness by promoting coordination and governance across
> jurisdictions to establish best practices for automated data
> collection, aggregation, and reporting.*

**Strategy 2.4.4:** Identify priorities, policies, and practices needed
to connect clinical care and research for the purpose of advancing
basic, clinical, and health services research.

> *Making comprehensive and timely data available for basic, clinical,
> and health services research through the exchange of electronic health
> information can advance medical knowledge. This strategy fosters a
> collaborative approach to identifying the data needs of researchers,
> promoting privacy protections for patients and consumers (including
> informed consent), and establishing best practices for aggregating and
> sharing clinical data sources for research.*

**Strategy 2.4.5:** Create accountability for organizations responsible
for implementing policies and practices for exchange of electronic
health information.

> *Standard policies and procedures for entities that exchange health
> information can ensure that patient privacy protections are maintained
> as data are aggregated and shared for population health purposes. This
> strategy promotes consistent application of those policies and
> procedures through accountability mechanisms, including
> accreditation.*

**Strategy 2.4.6:** To the extent permitted by law, develop, implement,
and oversee a health data sharing strategy across federal agencies that
will leverage available electronic health information from multiple
sources to meet the needs of population health programs including public
health, biomedical research, quality improvement and emergency
preparedness.

> *Federal and public health programs that utilize population health
> information could be augmented by a data sharing strategy that enables
> access and use of standards-based sharing of electronic health
> information from clinical care providers. This strategy aims to
> increase federal use of electronic health data, to the extent
> permitted by law, by identifying programmatic needs and implementing a
> data sharing strategy to meet those needs. These steps will help
> federal agencies to analyze data requirements and availability and
> support standardized procedures for data sharing necessary to realize
> the full benefit of using electronic health information to support
> population health programs.*

**Recent Federal Government Progress**

Several federal agencies are involved in multiple initiatives that will
advance this objective. This work has at times been informed by certain
federal advisory body recommendations that were submitted to the
Secretary of HHS. Table 2.4 provides a list of these initiatives along
with the appendix page where a summary of each can be found. The
majority of their activities focus on coordinating emergency
preparedness and other population health oriented initiatives.
Activities also seek to build consensus among a broad range of health IT
stakeholders on federal and state health IT priorities and policies that
affect the range of population health activities including research and
quality improvement.

+-----------------------------------------------------------------------+
| **Table 2.4 -- Current Health IT Initiatives and Federal Advisory     |
| Committees Addressing Objective 2.4**                                 |
+-----------------------------------------------------------------------+
| **Federal Agency and Department Initiatives**                         |
+-----------------------------------------------------------------------+
| > **ASPR:** Homeland Security Presidential Directive 21 (Page A32),   |
| > Pandemic All-Hazards Preparedness Act (PAHPA: Page A33)             |
+-----------------------------------------------------------------------+
| > **NIH:** Clinical Translational Science Awards (Page A42)           |
+-----------------------------------------------------------------------+
| > **ONC:** Federal Interdepartmental Health IT Collaborative          |
| > \[Multi-agency\] (Page A46), Federal Health Architecture (FHA)      |
| > \[Multi-agency\] (Page A47), Federal Interagency Health IT Policy   |
| > Council \[Multi-agency\] (Page A47), Planning for AHIC 2.0 (Page    |
| > A48), State Alliance for e-Health (Page A48)                        |
+-----------------------------------------------------------------------+
| **Other Public-Private Sector Initiatives**                           |
+-----------------------------------------------------------------------+
| > National Quality Forum (NQF: Page A62)                              |
+-----------------------------------------------------------------------+
| **Federal Advisory Committees**                                       |
+-----------------------------------------------------------------------+
| > National Committee on Vital and Health Statistics (NCVHS: Page A62) |
+-----------------------------------------------------------------------+
| > American Health Information Community (AHIC: Page A63), with its    |
| > workgroups on Population Health and Clinical Care Connections (Page |
| > A66), Quality (Page A67)                                            |
+-----------------------------------------------------------------------+

**Appendix A: Strategies, Milestones and Action Items**

**[Strategies for Objective 1.1]{.underline}**

***Privacy and Security:* Identify any policy issues, gaps or barriers**
-- **and advance the development of approaches** -- **to facilitate the
electronic exchange, access, and use of health information, while
protecting the privacy and security of patients' health information.**

**Strategy 1.1.1**: Develop a confidentiality, privacy, and security
framework for policy development to promote patient and consumer trust
in, and advance the electronic exchange of, health information.

Because privacy and security policies currently differ between the
federal and state levels, across states, across organizations, and among
distinct stakeholders and users of data, this strategy is critical to
establishing guidance for policy development relative to the exchange of
electronic health information within and across jurisdictions. EO 13335
requires the Strategic Plan to address privacy and security issues
related to health IT. The FY 2008 Congressional Appropriations Committee
Report (House Report Number 110-231) requested that ONC develop a
"confidentiality, privacy and security framework." Building from HIPAA
and other existing Federal privacy and security laws such as the Privacy
Act and the Federal Information Security Management Act, a
confidentiality, privacy, and security framework will be the result of a
federally led effort involving stakeholders community-wide and will
serve to promote trust among consumers and users of electronic
individual health information and to guide all efforts to advance the
exchange of electronic health information for the care and treatment of
patients. Confidentiality, privacy, and security principles will serve
as a resource for developing organizational and state governmental
policies and will aid the further development of federal governmental
policies. HHS will explore the possible use of federal procurement and
agency programs for these principles to gain traction.

The following illustrative actions supporting this strategy address the
need to engender the public's trust in the exchange of electronic health
information for health care delivery. Stakeholders need to be engaged in
a transparent and inclusive process to develop a confidentiality,
privacy, and security framework:

-   Based on common themes identified in published sets of privacy and
    security principles, develop a draft confidentiality, privacy, and
    security framework for policy development.

-   Obtain federal government and public, which includes consumers,
    acceptance on the draft framework and develop the final framework.

-   Publish the confidentiality, privacy, and security framework.

This framework will take into account *health care delivery system*
needs, when addressing privacy and security as they relate to the
exchange of electronic health information for health care delivery
purposes.

*Milestone 1.1.1: In 2008, ONC will publish a confidentiality, privacy,
and security framework and engage stakeholders in a dialogue regarding
the principles and health care delivery-related activities to foster
trust in the exchange of electronic health information among patients,
consumers, providers and other stakeholders.*[^4]

**Strategy 1.1.2:** Identify best practices for implementing technical
solutions to ensure confidentiality, integrity, and availability of
electronic health information consistent with the confidentiality,
privacy, and security framework.

In order to be accountable to the baseline principles established by the
confidentiality, privacy, and security framework, the technical
capabilities of EHRs, PHRs and other consumer health IT tools,
individually-oriented health data bases, and networks for the exchange
of health information will need to be examined and may require
adaptations. The following illustrative actions supporting this strategy
will leverage existing expert resources to develop guidance on technical
solutions:

-   Conduct outreach to relevant stakeholders to understand current and
    emerging practices and technologies for appropriately managing and
    enforcing the confidentiality, integrity, and availability of
    electronic health information (e.g., discuss with various types of
    health care stakeholders the current EHR/PHR systems being used in
    order to understand what practices may be implemented by using and
    building on existing technologies).

-   Identify the range of best practices for implementing technical
    solutions for confidentiality, integrity, and availability of
    electronic health information consistent with the confidentiality,
    privacy and security framework.

-   Collaborate with relevant agencies and offices to publish guidance
    on best practices for implementing technical solutions for
    confidentiality, integrity, and availability of electronic health
    information.

*Milestone 1.1.2**:** By 2010, disseminated best practices for
implementing technical solutions for the confidentiality, integrity, and
availability of electronic health information are used to inform
standards development, as well as recognized certifying bodies'
electronic health record and network certification criteria.*

**Strategy 1.1.3:** Facilitate state-based activities to identify and
address challenges to the use of health information technology, and the
intra- and inter-jurisdictional exchange of electronic health
information, while preserving or enhancing the current level of patient
protections.

Many state laws that address or impact privacy or the disclosure of
electronic health information were written before interoperable health
IT and the widespread exchange of electronic health information were
feasible and became commonplace and, as such, may inadvertently and
unnecessarily prohibit or significantly limit the appropriate exchange
of electronic health information. In addition, certain conflicts and
inconsistencies exist among these various statutes, regulations, and
policies, whether perceived or real, which present challenges to the
appropriate electronic exchange of health information. As in the
previous strategy, it is important to emphasize the importance of
preserving or enhancing patient and consumer protections. The following
illustrative actions supporting this strategy highlight ONC's role to
facilitate state efforts to reach consensus on how to appropriately
address such challenges to both intra- and inter-state exchange of
electronic health information:

-   Facilitate the evaluation of relevant state statutes, policies, and
    practices regarding privacy and security protections and data access
    restrictions -- to identify challenges to the use of health IT and
    the intra- and inter-state exchange of electronic health
    information.

-   Facilitate the identification of common approaches for addressing
    challenges to the use of health IT and the intra- and inter-state
    exchange of electronic health information, while assessing the
    extent to which those approaches could impact crucial patient and
    consumer protections.

-   Foster the development of guidance for state-based best practices
    that identify and address challenges to: the use of health IT, the
    exchange of electronic health information, and opportunities for
    preserving and enhancing patient and provider protections.

*Milestone 1.1.3**:** By 2009, states work collaboratively to develop
approaches for greater commonality to facilitate the exchange of
electronic health information and preserve or enhance the current level
of protections.*

**Strategy 1.1.4:** Increase stakeholder understanding of current
federal health privacy and security statutes and regulations in order to
promote trust in the use of health information technology and the
exchange of electronic health information for health care treatment
purposes.

Misinterpretation and misapplication of federal health privacy and
security statutes and regulations result in a reluctance by providers to
share patients' personal health information for health care delivery
purposes. In addition, patients' lack of understanding of these privacy
and security statutes and regulations, and of the rights the laws afford
them, contribute to mistrust, which limits the exchange of electronic
health information. The following illustrative actions that support this
strategy focus on increasing stakeholder trust in the exchange of
electronic health information for health care delivery purposes by
identifying the areas of greatest concern and providing education:

-   Compile misconceptions/misunderstandings about consumer privacy and
    security protections.

-   Develop educational tools to increase stakeholder, including patient
    and consumer, understanding of federal privacy protections.

-   Develop guidance to clarify select federal privacy and security
    statutes and regulations as they apply to the exchange of electronic
    health information.

*Milestone 1.1.4: By 2009, stakeholder-specific guidance that clarifies
select federal privacy and security statutes and regulations as they
apply to the exchange of electronic health information is published and
made available to all stakeholders.*

**Strategy 1.1.5:** Identify and evaluate approaches to address federal
statutes or regulations that conflict or are inconsistent -- or are
perceived to conflict or be inconsistent \--with the exchange of
electronic health information for health care delivery, while preserving
or enhancing patient protections.

Some federal statutes and regulations that address or impact the
disclosure of health information were written before interoperable
health IT and widespread electronic exchange of health information were
contemplated, and as such, may inadvertently and unnecessarily prohibit
or limit the appropriate exchange of electronic health information for
care and treatment purposes. In addition, perceived inconsistencies
among these various statutes, regulations, and policies present further
challenges to the appropriate electronic exchange of health information.
The following illustrative actions supporting this strategy promote an
inclusive process for addressing those areas in which federal
regulations pose challenges to the exchange of electronic health
information, while maintaining or enhancing current levels of patient
and consumer privacy protections:

-   Work with federal agencies to identify statutes, regulations, or
    policies that may inadvertently and unnecessarily prohibit or limit
    the appropriate use of health IT and the exchange of electronic
    health information and, as authorized, seek changes that would
    address such restrictions.

-   Work with consumer and industry representatives to identify ways to
    preserve or enhance patient protections.

-   Engage in activities (e.g., developing guidance) to address
    challenges created by federal regulations.

*Milestone 1.1.5: Guidance is published by relevant agencies related to
the exchange of electronic health information to appropriately improve
the consistency and currency of policy by 2011.*

**\*\*\*\***

**[Strategies for Objective 1.2]{.underline}**

***Interoperability:* Enable the exchange of interoperable health
information among health care providers and organizations, as well as
patients and their designees, to support patients' health and care
needs.**

**Strategy 1.2.1:** Advance the identification, availability, and use of
specified data and technical standards for interoperability that meet
critical provider and individual information needs.

This strategy is critical to establishing a foundation of common,
recognized interoperability standards and specifications for the
exchange of health information. It builds on existing standards
harmonization efforts, leverages the provisions of Executive Order 13410
that seek to advance recognized interoperability standards (see Page
15), and supports the development of new health information exchange
standards where necessary. The following illustrative action steps will
increase the availability and use of highly specified data and technical
standards:

-   Continue to prioritize and expand a set of common data elements in
    EHRs, PHRs, and other consumer health IT tools necessary to enable
    critical provider and patient information needs through
    interoperable health information networks.

```{=html}
<!-- -->
```
-   Promote efforts to ensure inclusion of appropriate and consistent
    data and technical standards into certification requirements for
    EHRs, PHRs, and other consumer health IT tools and networks.

-   Ensure that standards are used in relevant federal contracts,
    consistent with the EO 13410, "Promoting Quality and Efficient
    Health Care in Federal Government Administered or Sponsored Health
    Care Programs" (see description of "Value-Driven Health Care," in
    Appendix C, page A53).

*Milestone 1.2.1: By 2009, federal government entities (and their
contractors) will have initiated and will continue to facilitate the use
of critical data interoperability standards as well as agreements
covering electronic data.*

**Strategy 1.2.2:** Identify core capabilities and governance necessary
for networks to work with other networks in support of secure exchange
of electronic health information using non-proprietary standards.

Health information exchange solutions and networks have frequently been
developed to meet specific, often proprietary, needs. Each solution has
a unique mission and set of technologies, policies, and governance. As a
result, many networks cannot easily exchange information with other
networks. This strategy is critical to ensuring that disparate networks
are able to communicate with each other. The following illustrative
action steps will promote widespread interoperability of health
information networks and enable non-proprietary exchange of information:

-   Leverage existing electronic data inter-exchange systems that
    transport sensitive data and work with evolving health information
    networks to understand the range of network services, policies, and
    governance structures.

-   Promote the development of standards for requisite data and
    technical needs in the certification of health information exchange
    networks to support core services, including security, through the
    NHIN and HITSP.

-   Assist in identifying the specifications that support
    network-to-network exchange for enhanced care delivery and patient
    self-management.

*Milestone 1.2.2: By 2009, core service capabilities and data use
agreements for sharing health information through a network will be
publicly available for national, state, interstate, local, and tribal
health information networks to use when exchanging health information.*

**Strategy 1.2.3:** Foster the business case for the self-sustaining
exchange of health information in communities, states, and nationwide.

Sustainable exchange of health information within and across regions and
states is essential to improve patient care and health. Federal and
state governments need to consider and evaluate policy options to
encourage participation in the exchange of health information through
regional, state, and other networks that use recognized interoperability
standards and NHIN specifications. The following illustrative action
steps begin to explore ways to advance the business case:

-   Determine mechanisms and approaches to develop sustainable exchange
    of health information, a market for service providers and products
    enabled by the exchange of health information.

-   Identify the role of government in supporting the development of the
    exchange of health information nationwide.

-   Evaluate the value of the exchange of health information to various
    stakeholders in communities with operational data exchange across
    providers.

*Milestone 1.2.3: By 2009, an approach is determined for developing a
robust, competitive market, informed by emerging evidence related to the
value of the exchange of health information.*

**Strategy 1.2.4:** Increase the amount of health information being
exchanged electronically using the specified standards for the exchange
of health information -- to enhance the value for other providers,
provider organizations, and networks to adopt the standards.

The electronic exchange of health information has been hindered by a
variety of barriers, real and perceived. This strategy is critical to
overcoming these challenges by promoting sufficient information
availability through provider participation. The federal government,
with support from relevant stakeholders, will enhance health information
available for exchange and support a range of approaches and models
designed to support the exchange of health information. An NHIN that
connects several models of information exchange---geographically based
entities (RHIOs and regional HIEs), integrated delivery systems, and
health data banks for personally controlled health records\--through the
use of interoperability standards will enable greater information
exchange across more diverse users and settings. The illustrative action
steps will help gauge participation and promote connectivity:

-   Monitor engagement levels and measure growth in the exchange of
    health information across care settings.

-   Identify and address barriers to provider and patient involvement in
    the exchange of health information.

-   Connect standards-based initiatives for the exchange of health
    information at federal, state, local, and tribal levels that have
    electronic health information available for providers and provider
    organizations.

*Milestone 1.2.4: By 2010, providers and provider organizations will use
recognized interoperability standards and NHIN specifications to connect
their health* *information networks with other providers and provider
organizations.*

**Strategy 1.2.5:** Promote the development of the processes and
infrastructure for testing, verification and implementation of the
recognized standards and services, and nationwide policies in networks,
connected systems, and health IT.

The development and harmonization, of data and technical standards and
policies into certification requirements is necessary but not sufficient
for the continued growth and enhanced capabilities of interoperable
networks. The ability to test for and verify the implementation of these
standards in deployed systems is critical to ensuring consistent
implementation of data standards, services, and policies needed to
support interoperable exchange of health information. The following
illustrative action steps will help strengthen and enhance verification
processes to include testing and validation functions:

-   Support efforts to certify the exchange of health information and
    connected systems.

-   Promote the development of the processes and infrastructure for
    testing and verifying that data and technical standards and policies
    needed to support interoperability are being implemented.

-   Promote processes and the provision of services that enable health
    information service provider accreditation and network certification
    consistent with emerging data and technical standards and requisite
    data policies, including appropriate access policies.

*Milestone 1.2.5: By 2010, testing tools and data, as well as testing
criteria for certifying standards and services, are available.*

**Strategy 1.2.6:** Encourage health care organizations to provide
personal health information in useable standardized electronic form to
consumers or their designees.

Many health care organizations do not offer electronic availability of
personal health information to consumers or their designees. Strategy
1.2.6 is critical to ensuring that individuals have full electronic
access to their health information and can play an active role managing
their own health care using tools and services of their choice. This
availability will also help with portability across different provider
organizations. The action steps supporting this strategy foster the
availability of electronic health information (when available in
electronic form by the health care organization) to consumers or their
designees to enable them to better manage their own health and health
care. The following illustrative action steps will help establish a
foundation for the development of secure consumer health IT tools and
health care providers and organizations to support consumer access:

-   Identify and prioritize the electronic personal health information
    needs of consumers and their designees.

-   Demonstrate consumer-oriented uses of electronic personal health
    information using the NHIN core services.

-   Support development of processes to certify the security and
    portability of personal health records, health data banks, or other
    consumer health IT tools that could interface with interoperable
    health information networks.

*Milestone 1.2.6: By 2012, consumers and their designees or surrogates
have increased access to and use of personal health information via
interoperable health information networks or technologies.*

**Strategy 1.2.7:** Increase the availability of health information
service providers that compete to support the exchange of health
information.

A number of different models for the exchange of health information have
emerged across the country, but most organizations still cannot exchange
standards-based data with others. Exchange must be supported in many
unique ways in many locations. This strategy is critical to supporting
interoperable health information networks by encouraging a market for
companies supporting standards-based services for the exchange of health
information. The following illustrative action steps will help foster a
marketplace for accredited health information service providers in many
jurisdictions:

-   Document the range of health information service providers, their
    services, and the breadth of their availability.

-   Work with voluntary consensus based standards organizations (e.g.,
    HITSP) to identify a minimum set of standards for certification
    and/or accreditation of health information service providers and
    foster their use nationwide.

-   Work with industry representatives to identify barriers, such as
    potential liability issues, regulatory uncertainties and inter-state
    conflicts, to offering health information services.

The ultimate goal is to enable all types of electronic health
information, including lab results, prescription histories, medical
images and information from health care tools (e.g., blood pressure
readings, risk assessment tools and other monitoring devices) and more,
to flow into an EHR or PHR to form a comprehensive portrayal of the
patient's health.

*Milestone 1.2.7: By 2012, a consistent and visible increase in the
number of commercial health information service providers to meet the
growing demand of heath organizations and individuals who desire to
exchange information electronically.\
\
\
***Strategy 1.2.8:** Through the identification and recognition of
standards, empower individuals to use their health data to serve their
needs beyond direct patient care delivery.

There are a number of uses for medical data outside of care delivery and
population health, such as disease prevention, immunization records
required for school attendance, and entitlement determinations for
disability benefits. These potential uses present their own unique
challenges to data access -- including consumer control over how data is
used, and by whom. Consumers and their designees must understand the
range of possible uses of their data outside of health care delivery and
population health in order to make informed choices about permitting
access to their data. Additionally, appropriate standards need to be
developed to ensure that users of a patient's health information can
operate within the parameters authorized by law or by the patient and
his/her designees, and so that EHRs and PHRs can support the automated
exchange of medical information for non-health care purposes. Moreover,
developing the value proposition for exchanging medical information for
these purposes will help health care delivery and population health
agencies and organizations understand the benefits of supporting these
consumer needs. The following illustrative action steps will serve to
expand the discussion about standards, to adapt to these needs and to
provide benefits to the overall health care system:

-   Work with voluntary consensus based standards organizations (e.g.,
    HITSP and HL7) to identify standards gaps and develop appropriate
    standards.

-   Work with consumer representative organizations to educate the
    consumer on the values and options of using medical information for
    non-health care purposes.

-   Develop a value proposition to inform health care delivery and
    population health agencies and organizations of consumer benefits of
    exchanging medical information for non-health care purposes.

*\
Milestone 1.2.8: By 2009, standards exist for handling the patient's
authorized release of information to a trusted entity for non-health
care purposes.\
\
*

*\
*\*\*\*\*

**[Strategies for Objective 1.3]{.underline}**

***Adoption:* Promote the nationwide adoption of interoperable
electronic health records (EHRs) by providers, and the adoption of
personal health records (PHRs) and other consumer health IT tools by
consumers and their designees.**

**Strategy 1.3.1:** Remove business barriers and disincentives for
provider and delivery system adoption of EHRs.

Current EHR adoption rates remain low among both physicians and
hospitals. The high cost of procurement, implementation, and maintenance
of both IT hardware and EHR software are a primary barrier to more
widespread adoption. Furthermore, evidence suggests that return on EHR
investment accrues towards the payers of health care (health insurers,
employers, and consumers), more than to providers, even though providers
can realize some financial benefit. The relationship of malpractice
premiums to EHR use is a complex issue that could be the source of
strong incentives for adoption of EHRs. The following illustrative
actions steps are designed to minimize these provider barriers to EHR
adoption, better quantify benefits that accrue to various stakeholders
when EHRs are fully implemented, and develop promotion programs that
leverage these benefits and ultimately drive widespread adoption.

-   In coordination with public and private sector efforts, a five year
    demonstration project to evaluate types of incentives that promote
    adoption of certified EHRs among providers has been launched. (This
    is the CMS Demonstration discussed elsewhere in this document.)

-   Evaluate the costs and benefits to various stakeholders that promote
    interoperable health IT.

-   Confirm through literature reviews and perhaps studies that use of
    interoperable health IT reduces medical errors and improves patient
    care.

*Milestone 1.3.1: By 2010, physicians using certified EHRs are eligible
for malpractice credit.*

**Strategy 1.3.2:** Increase the likelihood of efficient and effective
EHR purchase and implementation.

The EHR adoption process for providers is complicated, time consuming,
and includes multiple steps (e.g., readiness assessment, vendor
selection, workflow redesign, and contract

negotiations). The actual EHR implementation process is also complicated
and decreases productivity in the short term. Without sufficient
provider training and support during these processes, failure rates can
be significant. The following illustrative action steps are intended to
lead to a better understanding of these challenges and provide
information to physicians and others so that they may confidently invest
in and effectively use their EHRs.

-   Evaluate various private and public approaches to supporting
    providers through the EHR adoption process with respect to
    efficiency, provider satisfaction, and adoption success rates.

-   Work with vendors to develop and offer guidance on efficient
    implementation and effective use as components of their
    "implementation support package."

-   Collaborate with medical societies and associations to ensure that
    information on the adoption process is readily available to all
    interested providers.

*Milestone 1.3.2: By 2009, information on low-cost, effective and
user-friendly approaches for provider support for the EHR adoption
process is available through web linkages from multiple sources.  *

**Strategy 1.3.3:** Increase value of EHRs through interoperability,
clinical decision support, and other technical advances.

EHR adoption, particularly in the office setting, can be both disruptive
and costly. As a result, some providers may be hesitant to invest in
such products, which ultimately contributes to low adoption rates. To
offset these factors and to stimulate adoption of such products and to
improve patient safety and the quality and efficiency of health care,
providers must realize a high degree of value from EHRs and related
technologies. Such value derives from clinical decision support,
workflow enhancements, and access to more complete and better organized
information. The following illustrative action steps support this
strategy's focus on the technical aspects of an EHR that can enhance
care delivery and thus create value for physicians and other health care
practitioners.

-   Develop a set of use cases for HITSP harmonization of
    interoperability standards and certification processes that support
    the needs of providers in caring for their patients.

-   Incorporate EHR functionalities into health IT certification that
    decrease administrative burden.

```{=html}
<!-- -->
```
-   Incorporate EHR functionalities into health IT certification that
    provide clinical decision support at the point of care.

*Milestone 1.3.3: By 2010, certified EHRs include clinical decision
support.*

**Strategy 1.3.4:** Promote certified health IT products as critical
components and standards of clinical care.

Health IT can increase quality of care and improve efficiency in the
delivery system. Certification ensures that IT products have the
specific capabilities that enable these benefits. As more patients
become aware of and directly experience the related benefits, including
better access to and understanding of electronic health information,
patients will increasingly expect providers to invest in and regularly
use health IT in care delivery. The following illustrative actions
signal the federal government's commitment to the adoption of certified
EHR products and increase consumer exposure to certified EHRs, thus
facilitating a broader general understanding of their benefits.

-   Specify that, to the extent permitted by law, certified EHRs and
    products are necessary components for any federally funded programs,
    pilots, and demonstrations that include the use of health IT.

-   To the extent permitted by law, include language in federal
    contracts and grants. specifying that certified products and
    services should be used and encouraged in direct patient care
    purposes and for products and services directed to consumers.

-   Evaluate level of support necessary for safety net providers to
    invest in certified EHRs and develop ways to provide that support.

*Milestone 1.3.4: By 2010, the majority of health IT products used by
clinicians are certified.*

**Strategy 1.3.5:** Develop the workforce for health IT product
development and use.

In order to fully realize the benefit of health IT, a dedicated and
well-trained workforce is needed. Providers and staff must be trained to
use health IT, while vendors and other relevant stakeholders must be
trained to support the implementation of these tools. A wide array of
professionals, including care providers, educators, health IT vendors,
and standards developers will be required to support the transition to
IT enabled health care delivery. The following illustrative action steps
facilitate the development of a robust and comprehensive workforce
supported throughout the industry.

-   Evaluate workforce needs for development, implementation, use, and
    maintenance within the areas of clinical knowledge, biotechnology,
    public health, and research.

-   Working with OPM, promote designation of Federal health IT positions
    within the occupational classification system.

-   Engage health professional licensing bodies in incorporating
    informatics competencies in the licensing process.

-   Incorporate informatics competencies in Federal academic programs,
    mentorship/fellowship programs to the extent permitted by law.

*Milestone 1.3.5: Study released by 2010 that quantifies the workforce
needed to support the near-term and long-term priorities to support
national deployment of interoperable health IT.*

**Strategy 1.3.6:** Identify key PHR functions and features that will
allow individuals to link their health information to a wide variety of
market driven personal health tools that they and their designees find
valuable in managing their heath and care.

The current low rate of adoption of PHRs and other consumer health IT
products, services, and tools may reflect a lack of understanding of
what they do and the benefits they provide, what privacy and security
protections are in place, how they link to and communicate with other
products and services, and the features and functions individuals find
valuable in managing their health. The following illustrative action
steps supporting this strategy address these issues, and provide
opportunities to better meet the needs of multiple and diverse
populations.

-   Develop clear definitions for constructs and terms related to
    consumer/patient controlled personal health information products and
    services.

-   Promote certification processes for personal health information
    products and services regarding interoperability standards, security
    standards, and consistent privacy policies.

-   Develop a standardized "disclosure" statement that informs consumers
    about the privacy policies of market driven consumer oriented tools
    and services.

*Milestone 1.3.6: By 2009, consensus is reached regarding the basic
components of a certified personal health record.*

**Strategy 1.3.7:** Design methods to promote the use of PHRs and other
consumer health IT tools by consumers and their designees.

The types of health information important to consumers, how it is
protected, how it is presented, and how it will be used are still poorly
understood. The role of incentives, both financial and non-monetary, to
promote adoption of PHRs is also unclear. The following illustrative
action steps supporting this strategy are intended to increase the
understanding of consumer use of consumer-oriented health IT products
and services, the current incentives in place and their impact, and
better support widespread adoption through various promotion strategies,
including communication on privacy and security protections.

-   Develop appropriate education for consumers on the value of health
    IT.

```{=html}
<!-- -->
```
-   Create consumer guidance tools on issues related to privacy,
    security, and interoperability.

-   Promote the availability of PHRs and other consumer health IT
    products and services to specific populations, such as individuals
    in rural areas and the underserved.

These and other steps will also serve to engage other stakeholders in
promoting adoption.

*Milestone 1.3.7: By 2010, creation of a plan that can guide efforts
directed at developing and marketing personal health information tools*

**Strategy 1.3.8:** Minimize liability risks and clarify misperceptions
of liability risks for providers using health IT, while preserving or
enhancing patient protections.

There are both real and perceived liability risks associated with
provider adoption of EHRs and participation in the exchange of
electronic health information. Supporting providers in fully and
accurately understanding these risks and how best to mitigate those that
are real is critical to increasing adoption. This is a market-driven
strategy because certification can ensure that the IT products have the
functional features that can mitigate risk. The following illustrative
action steps seek to clarify and disseminate information on these real
and perceived liability risks, and to identify technical solutions that
can be incorporated into EHR products to mitigate risk.

-   Engage medical societies, associations, and federations of state
    licensing boards in disseminating factual information regarding
    medical liability, health IT, and the exchange of electronic health
    information.

-   Promote in the recognized certification bodies' certification
    requirements, functional criteria that can improve decision-making
    (e.g., clinical decision support) and reduce errors.

-   Conduct annual surveys of various types of providers that include
    measures of perceived liability risk.

*Milestone 1.3.8: By 2011, providers have increased understanding of
liability risks in using health IT and engaging in the exchange of
electronic health information.*

**Strategy 1.3.9:** Remove technical, financial, workflow, and other
barriers to diagnosing, treating, and communicating with patients
outside the boundaries of traditional health care settings.

Health IT, and the electronic exchange of patient information that it
enables, are rapidly transforming how health care can be delivered.
Remote devices allow providers to deliver care and monitor patients,
regardless of the location of the patient. Many technical, legal,
financial and workflow barriers, however, prohibit widespread adoption
of technologies that support improved communication, diagnosis, and
treatment outside of the clinical setting. The following illustrative
action steps focus on understanding the sources of these barriers and
identifying solutions to promote widespread use of these technologies in
the future.

-   Support on-going and new programs that evaluate both the cost and
    quality outcomes associated with the provision of care supported by
    care using communications and technologies outside of the clinical
    setting.

-   Support the harmonization of standards for interoperability of data
    generated by remote monitoring devices.

-   Remove barriers to electronic communications between patients and
    their providers as an evidence-based first step in engaging
    consumers in using health IT to manage their own health.

*Milestone 1.3.9: By 2012, results of public/private collaborations
supporting secure messaging pilots in three independent sites are
published.*

**\*\*\*\***

**[Strategies for Objective 1.4]{.underline}**

***Collaborative Governance:* Establish mechanisms for equitable and
balanced multi-stakeholder priority-setting and decision-making to
achieve a secure, nationwide, interoperable health information
technology infrastructure.**

**Strategy 1.4.1:** Establish a national public-private governance
entity to advance interoperability and sustainable exchange of health
information nationwide.

It is important that the priorities and activities surrounding the
nation's health IT agenda be defined and governed by an objective,
equitable, broadly representative, and transparent entity. The action
steps supporting this strategy are designed to ensure governance at
national, state, and local levels to implement policies and procedures
for appropriate use and exchange of electronic health information. This
strategy recognizes the exchange of health information for care delivery
as the first priority for widespread adoption, but as the current AHIC
has considered when formulating its recommendations to HHS, these health
care requirements must be coordinated with those necessary to meet
population health needs. The following illustrative steps in conjunction
with other action steps will help ensure the establishment of
representative multi-stakeholder governance for the exchange of health
information at national, state, local, and tribal levels and help ensure
that broad perspective and priorities are considered:

-   Establish a successor to the current AHIC (currently being referred
    to as "AHIC 2.0") that will assume new governance and priority
    setting responsibilities related to health information standards and
    interoperability.

-   Ensure AHIC 2.0 develops an equitable, balanced, and broadly
    representative multi-stakeholder approach to identify priorities and
    key governance issues for automated electronic exchange of health
    information.

-   Support development of accreditation of governance entities for the
    exchange of health information across national, state, and local
    levels.

*Milestone 1.4.1: By 2009, a fully operational entity with broad
representation from the public and private sectors that provides
effective oversight of electronic data exchange and uses across the
country.*

**Strategy 1.4.2:** Empower consumers through representation in
multi-stakeholder governance entities at the national, state, and local
level.

Consumer participation in national, state, and local level governance
entities is necessary to ensure representation of consumer interest.
This level of consumer involvement will enable health IT initiatives to
better reflect consumer priorities, ensure public trust, and maximize
consumer welfare. The action steps below emphasize the importance of
consumer involvement in developing policies and procedures around the
exchange of health information, identify and disseminate best practices
and models for engaging consumers, and work to promote actual consumer
involvement in activities nationwide. The following illustrative steps
in conjunction with other action steps will help ensure that
perspectives and priorities of consumers are appropriately reflected in
policies and governance for the exchange of health information
nationwide.

-   Encourage multi-stakeholder governance models that incorporate
    consumer perspectives and preferences in policies and operations for
    the exchange of health information.

-   Identify best practices for multi-stakeholder governance models that
    promote effective and efficient decision making -- and promote
    consumer engagement in multi-stakeholder governance activities at
    the federal, state, local, and tribal levels.

```{=html}
<!-- -->
```
-   Support development of accreditation of governance entities for the
    exchange of health information across national, state, and local
    levels.

*Milestone 1.4.2: By 2011, consumers consistently participate in
activities related to the exchange of health information and in related
oversight bodies across the country, and ensure that consumer
perspective is represented and valued in these processes.*

**Strategy 1.4.3:** Promote participation by federal, state, local, and
tribal government representatives in multi-stakeholder governance
entities for the exchange of health information at all appropriate
levels: national, state, and local.

Coordination and mutual participation by federal, state, local, and
tribal government representatives is needed to ensure communication and
align priorities regarding the use and exchange of health information
that supports patient-focused health care nationwide. Participation is
needed for government representatives on health IT governance entities
at their geographic level and above. The illustrative action steps below
are designed to sustain regular and organized interaction,
collaboration, communication, and participation in such activities. The
action steps also emphasize the need to promote shared and complementary
participation in governance activities and to align goals and policies
for the exchange of electronic health information across all geographic
levels nationwide:

-   Identify the range of governance functions for the exchange of
    electronic health information at the national, state, local, and
    tribal levels.

-   Support communication and collaboration across national, state,
    local, and tribal activities related to the exchange of health
    information -- to facilitate alignment of activities.

-   Support the priority setting process informed by federal, state,
    local, and tribal perspectives to ensure appropriate alignment and
    coordination of governance.

*Milestone 1.4.3: By 2011, mechanisms enable federal, state, and local
governance entities for the exchange of health information to have input
into transparent decision-making processes.*

**[Strategies for Objective 2.1]{.underline}**

***Privacy and Security:* Advance the development of privacy and
security policies, principles, procedures, and protections that
facilitate appropriate access to, or transfer and use of, electronic
health information for public health, biomedical research, quality
improvement, and emergency preparedness.**

**Strategy 2.1.1:** Employ the confidentiality, privacy, and security
framework (see Strategy 1.1.1) for policy development to establish
patient and consumer trust and advance the exchange of electronic health
information for population health purposes.

Because privacy and security policies currently differ between the
federal and state levels, across states, across organizations, and among
distinct stakeholders and users of data, this strategy is critical to
establishing guidance for consistent confidentiality, privacy and
security policy-development relative to the electronic health
information exchange within and across jurisdictions. As described under
Strategy 1.1.1, Executive Order 13335 requires the Strategic Plan to
address privacy and security issues related to health IT. Building from
HIPAA and other existing Federal privacy and security laws, such as the
Privacy Act and the Federal Information Security Management Act, this
confidentiality, privacy and security framework will take into account
the information needs for the range of population health activities,
including public health, biomedical research, quality improvement, and
emergency preparedness.

The following illustrative actions supporting this strategy address the
need to engender the publics' trust in the exchange of electronic health
information for population health. Stakeholders need to be engaged in a
transparent and inclusive process to develop a confidentiality, privacy,
and security framework that provides guidance for policy development and
implementation:

-   Based on research on existing privacy and security principles,
    develop a draft confidentiality, privacy, and security framework, as
    noted in Strategy 1.1.1, that considers the needs of population
    health in the policy development process.

-   Obtain federal government and public acceptance on the draft
    framework and develop the final framework.

-   Publish final framework.

This framework will take into account the information needs for the
range of *population health activities*, including public health,
biomedical research, quality improvement, and emergency preparedness.

*Milestone 2.1.1: By 2008, ONC will publish a confidentiality, privacy,
and security framework and engage stakeholders in a dialogue regarding
principles around which population health organizations can develop
policies that enable appropriate, authorized, and timely access and use
of electronic health information, and that foster trust among patients
and consumers.*

**Strategy 2.1.2:** Identify and evaluate federal statutes or
regulations that conflict or are inconsistent -- or are perceived to
conflict or be inconsistent -- with the exchange of electronic health
information used for population health purposes, while preserving or
enhancing patient protections.

Similar to Strategy 1.1.5, some federal statutes and regulations related
to the disclosure of health information for population health uses were
written before interoperable health IT and widespread exchange of health
information were considered, and may inadvertently and unnecessarily
prohibit or limit the appropriate exchange of such information -- or may
be perceived to do so. The following illustrative actions supporting
this strategy suggest methods for addressing those areas related to
exchange of electronic health information used for population health
purposes in which federal laws pose -- or are perceived to pose --
challenges to the exchange of electronic health information, while
maintaining or enhancing current levels of patient privacy protections:

-   Work with federal agencies to identify regulations or policies
    regarding access to health care data for population health uses that
    may be conflicting, inconsistent, or outdated and to identify
    options for resolving conflicts or inconsistencies and updating
    those regulations or policies.

-   Work with agencies and industry to identify and evaluate approaches,
    consistent with the framework developed in Strategy 2.1.1, for
    resolving conflicts or inconsistencies and updating regulations or
    policies regarding access to health care data for population health
    uses and enhancing select protections.

-   Engage in activities (e.g., developing guidance) to address
    challenges created by federal regulations.

*Milestone 2.1.2: By 2011, relevant agencies will identify any such laws
and take appropriate action to facilitate the exchange of electronic
health information for population health purposes and preserve or
enhance patient protections.*

**Strategy 2.1.3:** Facilitate state-based activities to identify and
address challenges to the use of health information technology and the
intra- and inter-state exchange of electronic health information to
support population health, while preserving or enhancing the current
level of patient protections.

Many state laws that address or impact the privacy or the disclosure of
electronic health information were written before interoperable health
IT and the widespread exchange of electronic health information were
feasible, and as such, may inadvertently and unnecessarily prohibit or
significantly limit the appropriate exchange of electronic health
information. In addition, perceived inconsistencies among these various
statutes, regulations, and policies present further challenges to
appropriate health information exchange. As in the previous strategy, an
emphasis on the importance of preserving or enhancing patient and
consumer protections is also present here. The following illustrative
actions that support this strategy highlight ONC's role as a facilitator
of state efforts to reach consensus on how to appropriately address such
challenges to both intra and inter-state exchange of electronic health
information to support population health activities:

-   Facilitate the evaluation of relevant state laws, policies, and
    practices regarding privacy and security protections and data access
    restrictions to identify challenges to the use of health IT and the
    intra- and inter-state exchange of electronic health information for
    population health purposes.

-   Facilitate the identification of common approaches for addressing
    challenges to the use of health IT and the intra- and inter-state
    exchange of electronic health information for population health
    purposes, while assessing the extent to which those approaches could
    impact crucial patient and consumer protections.

-   Foster the development of guidance for state-based best practices
    that identify and address challenges to the use of health IT and the
    exchange of electronic health information for population health
    purposes, and opportunities for preserving and enhancing patient and
    provider protections.

*Milestone 2.1.3: By 2011, guidance will be published for states to
consider how to incorporate policies related to public health and
electronic exchange of health information based on consensus
recommendations.*

**Strategy 2.1.4:** Increase stakeholder understanding of current
federal health privacy and security laws in order to promote trust in
the use of health IT and exchange of electronic health information for
population health purposes.

Misinterpretation and misapplication of federal health privacy and
security laws result in a reluctance by providers to share patients'
personal health information for population health uses. Patients' lack
of understanding of these privacy and security statutes and regulations,
and of the rights the laws afford them, contribute to mistrust, which
limits the exchange of electronic health information. The following
illustrative actions that support this strategy focus on increasing
stakeholder trust in the exchange of electronic health information for
population health purposes by identifying the areas of greatest concern
and providing education:

-   Compile misconceptions/misunderstandings about consumer privacy and
    security protections.

-   Develop educational tools to increase stakeholder, including patient
    and consumers, understanding of federal privacy protections.

-   Work with relevant agencies and offices to develop guidance to
    clarify select federal privacy and security laws as they apply to
    the exchange of electronic health information for population health
    purposes.

*Milestone 2.1.4: By 2011, appropriate federal agencies will work with
stakeholders to identify issues and clarify, where appropriate, select
federal privacy and security laws as they apply to the exchange of
electronic health information for population health purposes.*

\*\*\*\*

**[Strategies for Objective 2.2]{.underline}**

***Interoperability:* Enable the secure exchange of interoperable health
information among health-related organizations -- as well as providers,
patients, and their designees -- to support appropriate
population-oriented uses.**

**Strategy 2.2.1:** Advance the availability and use of consistent data
and technical standards that enable the merging of comparable data
originating from multiple organizations and sources in support of
population health uses.

The exchange of electronic health information among different kinds of
organizations offers great value in enabling population health uses,
including public health, biomedical research, quality improvement, and
emergency preparedness. This strategy is critical to ensuring the
ability of different organizations to share and aggregate comparable
electronic health information. The following illustrative action steps
seek to advance EHR interoperability to include standards, technical
architecture and certification requirements that support data sharing
and use for population health purposes:

-   Define and prioritize a set of consensus based data and technical
    standards for EHRs that are needed to enable population health uses
    through interoperable health information networks.

-   Document and communicate identified gaps between available EHR
    standards and population health needs to relevant standards
    development organizations to inform their work plans and
    priority-setting processes.

-   Promote efforts to ensure inclusion of appropriate and consistent
    standards into certification requirements for EHRs and networks.

*Milestone 2.2.1: By 2009, population health-oriented users of
information will be able to receive comparable data from different
clinical sources through the use of consistent standards in clinical
care for the exchange of health information.*

**Strategy 2.2.2:** Allow for flexibility in the models for the exchange
of health information (organizational, geographic, and personally
controlled), while still advancing the specific standards and policies
necessary to ensure that they all work together to meet population
health needs.

This strategy supports different models for the exchange of health
information, and innovation in developing new capabilities and services,
while promoting consistency of standards to support interoperable
exchange of electronic health information. The strategy also addresses
the need to ensure that emerging technical standards for entities that
exchange health information support the minimal necessary set of
services and policies. The following illustrative action steps will help
establish a foundation for the emerging marketplace of entities that
exchange health information:

-   Work with evolving entities that exchange health information to
    understand emerging technical requirements, the array of technical
    architectures, and range of network services, policies, and
    governance structures.

-   Foster a dialogue among the array of population health information
    users and network providers on underlying reasons for and
    appropriate range of variation in network services, policies, and
    governance.

-   Monitor emerging marketplace for barriers to innovative health
    information architectural design.

*Milestone 2.2.2: By 2009, the exchange of standards for electronic
health information will support at least the three different models for
entities that exchange health information (organizationally-based,
geographically-based, and personally controlled), while providing data
for population health purposes.*

**Strategy 2.2.3:** Assess the implementation of recognized standards
and nationwide policies in entities that exchange health information.

Establishing the standards and policies that enable the exchange of
health information is the first step to ensuring interoperability and is
necessary but not sufficient for the continued growth and enhanced
capabilities of interoperable networks. This strategy is critical to
ensuring that organizations are able to appropriately and consistently
employ those standards and policies. The following illustrative action
steps will help strengthen and expand current standards development and
certification processes to allow for testing of standards
implementation:

-   Support efforts to certify the exchange of health information.

-   Develop processes and promote services that enable provider
    accreditation and network certification consistent with emerging
    data standards and requisite data policies, including appropriate
    access policies.

-   Ensure that standards and terminologies, including value sets, are
    maintained to support availability and currency of recognized
    standards.

*Milestone 2.2.3: By 2010, electronic verification capabilities will
actively ensure that those who exchange health information use
consistent standards and certification and, at times, accreditation will
ensure the implementation of standards and policies that promote
interoperability.*

**Strategy 2.2.4:** Promote the availability of health information in a
useable electronic form for appropriate population health users outside
of direct patient care.

This strategy is critical to ensuring that electronic health information
is available for population health needs, including public health,
biomedical research, quality improvement, and emergency preparedness.
This strategy builds on the emergence of an interoperable health
information network using the standards developed through the NHIN
initiative. It addresses the need to ensure that additional appropriate
population health uses are defined and enabled as networks evolve. The
following illustrative action steps draw on existing initiatives and
expertise to specify population health information uses and needs and
will help ensure that interoperable health information networks continue
to meet these needs:

-   Demonstrate population health uses of electronic health information
    through the NHIN trial implementations.

-   Specify the electronic health information needs of research,
    quality, and public health organizations.

-   Conduct ongoing evaluations of interoperable health information
    networks' ability to meet the evolving data needs of research,
    quality, public health, and emergency response organizations.

*Milestone 2.2.4: By 2010, those who use the Nationwide Health
Information Network specifications will begin to make aggregate
electronic health information available to appropriate population health
entities in a manner that meets their range of data needs.*

**Strategy 2.2.5:** Advance the availability of needed clinical and
resource information for providers and emergency response teams when
responding to significant events that affect population health.

Health IT and networks for the exchange of health information can
connect all members of emergency response teams -- from the top levels
of the federal government to the providers in the field -- and enable
timely access to comprehensive data. In particular, this strategy
acknowledges the recently issued Homeland Security Presidential
Directive (HSPD-21) establishing a National Strategy for Public Health
and Medical Preparedness. The cabinet level Task Force and advisory
committee established pursuant to this directive will play key roles in
determining what automated health information support is needed and
identifying current barriers to information availability and access.
Other federal agencies working with the disaster response community will
coordinate the Task Force efforts with relevant and needed standards and
network interoperability development activities to ensure these
requirements are addressed. The following illustrative action steps
support and will make certain that the capabilities created through the
NHIN can support emergency response:

-   Work with voluntary consensus standards organizations (e.g., HITSP)
    to identify needed functionality through development of use cases,
    standards, and certification requirements to support emergency
    response.

-   Advance critical network functionalities in the NHIN to support:

    -   Situational Awareness

    -   Emergency care

    -   Outbreak management

    -   Response management

    -   Emergency Communication

-   Identify barriers that could inhibit data access during disasters.

*Milestone 2.2.5: By 2010, those who use the NHIN specifications will
begin to provide information in a manner that meets the needs of
emergency response.*

> \*\*\*\*

**[Strategies for Objective 2.3]{.underline}**

***Adoption:* Promote the nationwide adoption of information
technologies that enable the reliable and efficient exchange of
electronic health information to continuously improve population health
activities and individual health care services.**

**Strategy 2.3.1:** Establish mechanisms to optimize the exchange of
information between care providers using EHRs and authorized users of
population health data, as well as among authorized users and recipients
of population health data.

The exchange of information between care providers and population health
data users enables greater accessibility and utility of population
health data for all parties. This strategy supports the efficient
transmittal of information between providers using EHRs and authorized
population health data users. The following illustrative action steps
will enable timely, automated, and secure mechanisms for data
transmittal:

-   Prioritize information for population health uses that can be
    readily accessed and shared.

-   Collaborate to identify and prioritize population health
    information, mechanisms to facilitate accessibility and use of
    electronic data, and technology and applications that support
    information exchange.

-   Identify and address gaps in interoperability standards for
    applications that electronically transmit population health
    information to providers.

These and other steps will contribute to best practices for the exchange
of health information between providers and population health data
users.

*Milestone 2.3.1: By 2012, standards will exist that increase the
automation of clinical information electronically sent and accessed by
providers and authorized population health data users.*

**Strategy 2.3.2:** Minimize burden on health care providers when
reporting clinical data for population health purposes using EHRs and
other health IT, while ensuring consistent health information
protections.

The increased burden associated with providing clinical data for
population health uses may limit participation by providers and other
data sources. This strategy aims to reduce the burden on the delivery
system by promoting efficient data collection and reporting. The
following illustrative action steps facilitate automated collection of
population health data and use of non-clinical data sources:

-   Identify methods to standardize or streamline queries made by
    authorized population health users to collect data for population
    health purposes (e.g., use of data brokers, automated data capture
    from standardized transactions).

-   Identify non-clinical sources currently maintaining electronic
    clinical health information, and determine if they can serve as
    alternative sources of provider data (e.g., claims databases,
    registries, labs, and consumers).

-   Develop guidance on using the range of alternate electronic data
    sources and explore the need for accreditation of these sources.

Along with other actions, these steps will encourage increased
participation and buy-in from providers and others that serve as data
sources. When federal agencies are the recipients of population health
data reporting, this strategy supports the intent and stipulations of
the Paperwork Reduction Act.

*Milestone 2.3.2: By 2012, certified EHRs will have features that enable
them to transmit automated data to population health agencies.*

**Strategy 2.3.3:** Establish mechanisms for the electronic exchange of
health information among authorized users of population health data,
communities, and individual consumers.

Consumers and communities are also sources of electronic health
information, and their information exchange with authorized population
health data users is subject to unique challenges and benefits. This
strategy supports the collection of appropriate information directly
from consumers as well as community sources, with appropriate privacy
protections in place, and the secure transmission of this information to
population health agencies that are authorized to receive it. It also
embraces dissemination of population health findings from population
health agencies to consumers and communities. The following illustrative
action steps are designed to identify and create tools to enable
consumers' and communities' transmittal and use of population health
data:

-   Identify data elements for population health uses for which
    consumers and communities may be a preferred or unique resource for
    collection and reporting, as compared to providers or other data
    sources (e.g., risk assessments or full medication lists including
    over-the-counter medications).

-   Support the development of population health applications that can
    interoperate with community- and consumer-based health IT tools to
    transmit population health information.

-   Promote education for communities and consumers on how to use
    population health data.

These actions, along with others, facilitate access and understanding of
consumer data by authorized population health data users, communities,
and individual consumers.

*Milestone 2.3.3: By 2012, one or more pilot projects will be underway
to explore the feasibility of the exchange of health information among
population health organizations, community-based organizations, and
individual consumers.*

\*\*\*\*

**[Strategies for Objective 2.4]{.underline}**

***Collaborative Governance*: Establish coordinated and effective
organizational processes---at the federal, state, local and tribal
levels---to promote the availability and management of aggregated
clinical information to benefit population health.**

**Strategy 2.4.1:** Establish and monitor the use of data stewardship
models that allow for capture and consistent use of electronic health
data for population health purposes through common practices compliant
with laws and organizational policies.

The primary focus of this strategy is to make needed data available to
authorized population health users by promoting appropriate data
stewardship within existing laws and organizational policies. Action
steps supporting this strategy establish a foundation to set data
priorities and define electronic health information uses for public
health, biomedical research, quality improvement, and emergency
preparedness. The following illustrative actions will serve as the basis
for a policy framework on the exchange of health information and data
stewardship for population health purposes:

-   Identify governance mechanisms needed to support the exchange of
    health information for population health purposes: governance to
    oversee how information is stored, reported, and/or analyzed.

-   Establish a national consensus on the definitions and differences
    between data capture for public health, biomedical research, quality
    improvement, and emergency preparedness.

-   Support the development of policy guidelines for the exchange of
    electronic health information and for population health data
    stewardship, based on the interaction of stewardship efforts at the
    federal, state, local, and tribal levels.

*Milestone 2.4.1: By 2010, data stewardship models will be established
that support appropriate use of electronic clinical data for public
health, biomedical research, quality improvement, and emergency
preparedness priorities.*

**Strategy 2.4.2:** In concert with federal partners, identify and
coordinate priorities, policies, and practices that are needed to
develop and implement quality measures in ways that are compatible with
different models for the exchange of health information.* *

This strategy addresses unique concerns related to the collection and
aggregation of electronic health information for defining and evaluating
quality of care. The strategy supports effective use of electronic
health data by facilitating standardized data elements aligned across
multiple stakeholders' quality measurement initiatives. Federal research
and development will be leveraged as needed to advance and improve
quality practices. The following illustrative actions promote the use of
an automated common set of electronic data elements from electronic
health records and entities that exchange health information:

-   Facilitate establishment of consistent roles and best practices at
    the national level that enable the automation of quality measurement
    and reporting.

-   Align federal initiatives to aggregate electronic clinical data for
    quality measurement and reporting with state, local, tribal, and
    private sector health care quality policies and activities.

-   Work with public and private stakeholders to support efforts to use
    a common set of nationally prioritized, patient-centric,
    longitudinal quality and efficiency measures in public reporting and
    payment, starting with a minimum data set for quality and
    standardized data elements.

*Milestone 2.4.2: By 2012, meaningful and standardized quality
measurement and feedback to providers will be reliably and validly
reported and disseminated electronically at local, regional, and
national levels.*

**Strategy 2.4.3:** Identify mechanisms, policies, and practices needed
to connect clinical care and public health for public health purposes,
including biosurveillance and emergency preparedness.

Public health data needs at federal, state, local, and tribal levels can
be enabled through automated data capture, exchange, and aggregation.
This strategy supports coordination and governance of data aggregation
at all levels. The following illustrative action steps will help
identify unique concerns for this type of data collection, facilitate
prioritization and planning, and advance the business case for the
exchange of electronic health information for public health,
biosurveillance, and emergency preparedness purposes/needs to ensure
private sector buy-in and participation:

-   In collaboration with tribal, local, state, and federal data
    stewardship entities, identify the unique challenges in aggregating
    and sharing electronic health information for public health
    purposes, including biosurveillance and emergency preparedness.

-   Work with states and other stakeholders to support the
    prioritization and planning for data capture and reporting to
    address broader public health issues (e.g., monitoring of nosocomial
    infections and adverse drug event monitoring).

-   Enhance the business case for exchanging electronic health
    information to meet public health needs including biosurveillance
    and emergency preparedness.

*Milestone 2.4.3: By 2010, there will be demonstrated coordination of
governance entities by an AHIC Successor (e.g., data use agreements)
across* *jurisdictions, public health agencies, and clinical care for
the purposes of advancing public health priorities.*

**Strategy 2.4.4:** Identify priorities, policies, and practices needed
to connect clinical care and research for the purpose of advancing
basic, clinical, and health services research.

Electronic health information can inform and advance medical knowledge
by providing data that enables more comprehensive and timely basic,
clinical, and health services research. This strategy intends to
increase the availability of aggregated data sources for research by
supporting data collected with appropriate patient protections. The
following illustrative action steps address the unique concerns of
research, including informed consent and Institutional Review Board
(IRB[^5]) approval:

-   In collaboration with tribal, local, state, and federal data
    stewardship entities, identify the unique challenges in aggregating
    and sharing electronic health information for basic, clinical, and
    health services research. Identify best practices for obtaining
    informed consent through paper and automated systems and aggregating
    data in ways to protect research participants.

-   Establish a process for streamlining IRB approvals as more
    electronic clinical data become available through electronic health
    records and interoperable networks.

*Milestone 2.4.4: By 2010, there will be demonstrated coordination of
governance entities across clinical care and research communities for
the purposes of advancing research.*

**Strategy 2.4.5:** Create accountability for organizations responsible
for implementing policies and practices for exchange of electronic
health information.

The ability of entities that exchange health information to effectively
aggregate and share data for population health purposes is dependent on
the use of appropriate policies and procedures. This strategy promotes
the standardization and accountability of data aggregation and
transmittal activities. The following illustrative action steps will
support capacity building, protocol development, and accreditation for
the exchange of health information:

-   In coordination with the federal data sharing strategy (Strategy
    2.4.6), conduct planning and prioritization activities to build
    capabilities and establish protocols for data capture and reporting
    to meet the many different needs of population health (e.g.,
    registries versus surveys).

-   Across the key areas of population health, examine the benefits and
    risks of aggregation practices at state, local, and tribal levels.

-   As appropriate, develop accreditation processes to facilitate
    consistent governance for exchanging electronic health information
    and for related data aggregation to support population health uses
    at a national, state, local, and tribal level.

*Milestone 2.4.5: By 2011, there will be established accreditation
criteria and processes for all models for the exchange of health
information, as appropriate.*

**Strategy 2.4.6:** To the extent permitted by law, develop, implement,
and oversee a health data sharing strategy across federal agencies that
will leverage available data from multiple sources to meet the needs of
population health programs including public health, biomedical research,
quality improvement, and emergency preparedness.

Federal and public health programs that utilize population health
information could be augmented by a data sharing strategy that
encourages access and use of information among them using
standards-based exchange of electronic health information. These action
steps aim to increase federal use of electronic health data, to the
extent permitted by law, by identifying programmatic needs and
implementing a data sharing strategy. The following illustrative actions
will help federal agencies analyze data requirements and availability
and support standardized procedures for data sharing and use:

-   Create an inventory of data each agency currently collects and from
    where it collects that data to meet research and programmatic needs
    and, ultimately, support each agency's individual mission.

```{=html}
<!-- -->
```
-   Develop and prioritize data requirements for federal programs
    consistent with the agency priority and missions and determine where
    knowledge gaps exist and what specific new data should be enabled.

-   Establish a cross-collaborative team to work with agency
    representatives to develop, identify, and prioritize policies,
    practices and protocols around how, consistent with the law, data
    should be requested, accessed and utilized within and across federal
    agencies.

    *Milestone 2.4.6: By 2012, federal data will be shared securely
    among federal agencies, to the extent permitted by law, for
    population health purposes, while protecting the privacy of
    individuals.*

    **Appendix B: Federal Health IT Initiatives and Federal Advisory
    Committee Activities Related to Strategic Plan Goals and
    Objectives**

    (Descriptions of the initiatives listed are found in Appendix C)

+------------------------------------+---+---+---+---+---+---+---+---+
|                                    | * |   |   |   | * |   |   |   |
|                                    | * |   |   |   | * |   |   |   |
|                                    | G |   |   |   | G |   |   |   |
|                                    | o |   |   |   | o |   |   |   |
|                                    | a |   |   |   | a |   |   |   |
|                                    | l |   |   |   | l |   |   |   |
|                                    | 1 |   |   |   | 2 |   |   |   |
|                                    | * |   |   |   | * |   |   |   |
|                                    | * |   |   |   | * |   |   |   |
+====================================+===+===+===+===+===+===+===+===+
|                                    | * | * | * | * | * | * | * | * |
|                                    | * | * | * | * | * | * | * | * |
|                                    | O | O | O | O | O | O | O | O |
|                                    | b | b | b | b | b | b | b | b |
|                                    | j | j | j | j | j | j | j | j |
|                                    | 1 | * | * | * | * | 2 | 2 | 2 |
|                                    | . | * | * | * | * | . | . | . |
|                                    | 1 |   |   |   |   | 2 | 3 | 4 |
|                                    | * | * | * | * | * | * | * | * |
|                                    | * | * | * | * | * | * | * | * |
|                                    |   | 1 | 1 | 1 | 2 |   |   |   |
|                                    |   | . | . | . | . |   |   |   |
|                                    |   | 2 | 3 | 4 | 1 |   |   |   |
|                                    |   | * | * | * | * |   |   |   |
|                                    |   | * | * | * | * |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| **ONC-Coordinated Federal Health   | > | > | > | > | > | > | > | > |
| IT Strategic Plan**                |   |   |   |   |   |   |   |   |
|                                    | * | * | * | * | * | * | * | * |
|                                    | * | * | * | * | * | * | * | * |
|                                    | P | I | A | C | P | I | A | C |
|                                    | r | n | d | o | r | n | d | o |
|                                    | i | t | o | l | i | t | o | l |
|                                    | v | e | p | l | v | e | p | l |
|                                    | a | r | t | a | a | r | t | a |
|                                    | c | o | i | b | c | o | i | b |
|                                    | y | p | o | o | y | p | o | o |
|                                    | > | e | n | r | > | e | n | r |
|                                    |   | r | * | a |   | r | * | a |
|                                    | a | a | * | t | a | a | * | t |
|                                    | n | b |   | i | n | b |   | i |
|                                    | d | i |   | v | d | i |   | v |
|                                    | > | l |   | e | > | l |   | e |
|                                    |   | i |   | > |   | i |   | > |
|                                    | S | t |   |   | S | t |   |   |
|                                    | e | y |   | G | e | y |   | G |
|                                    | c | * |   | o | c | * |   | o |
|                                    | u | * |   | v | u | * |   | v |
|                                    | r |   |   | e | r |   |   | e |
|                                    | i |   |   | r | i |   |   | r |
|                                    | t |   |   | n | t |   |   | n |
|                                    | y |   |   | a | y |   |   | a |
|                                    | * |   |   | n | * |   |   | n |
|                                    | * |   |   | c | * |   |   | c |
|                                    |   |   |   | e |   |   |   | e |
|                                    |   |   |   | * |   |   |   | * |
|                                    |   |   |   | * |   |   |   | * |
+------------------------------------+---+---+---+---+---+---+---+---+
| **Department of Health and Human   |   |   |   |   |   |   |   |   |
| Services**                         |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Agency for Healthcare Research &   |   |   |   |   |   |   |   |   |
| Quality (AHRQ)                     |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > AHRQ: Health IT Portfolio        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > AHRQ: United States Health       |   |   |   |   |   |   |   |   |
| > Information Knowledgebase        |   |   |   |   |   |   |   |   |
| > (USHIK)                          |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Assistant Secretary for Planning   |   |   |   |   |   |   |   |   |
| and Evaluation (ASPE)              |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ASPE: Health Information           |   |   |   |   |   |   |   |   |
| Activities                         |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Assistant Secretary for            |   |   |   |   |   |   |   |   |
| Preparedness and Response (ASPR)   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ASPR: Homeland Security            |   |   |   |   |   |   |   |   |
| Presidential Directive 21          |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ASPR: Pandemic All-Hazards         |   |   |   |   |   |   |   |   |
| Preparedness Act (PAHPA)           |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Centers for Disease Control and    |   |   |   |   |   |   |   |   |
| Prevention (CDC)                   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CDC: BioSense                      |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CDC: EPI-X                         |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CDC: National Healthcare Safety    |   |   |   |   |   |   |   |   |
| Network                            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CDC: Public Health Information     |   |   |   |   |   |   |   |   |
| Network                            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CDC: Public Health Preparedness    |   |   |   |   |   |   |   |   |
| Systems                            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Centers for Medicare & Medicaid    |   |   |   |   |   |   |   |   |
| Services (CMS)                     |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CMS: Beneficiary Information       |   |   |   |   |   |   |   |   |
| Services                           |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CMS: EHR Adoption Demonstration    |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CMS: E- Prescribing Efforts        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CMS: HIPAA Security Rule           |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CMS: ICD-10                        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CMS: Medicaid Information          |   |   |   |   |   |   |   |   |
| Technology Architecture (MITA)     |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CMS: Medicaid Reimbursement for    |   |   |   |   |   |   |   |   |
| Telehealth Services                |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| CMS: Medicaid Transformation       |   |   |   |   |   |   |   |   |
| Grants                             |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Food & Drug Administration (FDA)   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| FDA: Sentinel Network              |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| FDA: Structured Product Labeling   |   |   |   |   |   |   |   |   |
| for Products                       |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Health Resources and Services      |   |   |   |   |   |   |   |   |
| Administration (HRSA)              |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| HRSA: *Connections* Project        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| HRSA: Rural Hospital Flexibility   |   |   |   |   |   |   |   |   |
| Grant Program -- FLEX              |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| HRSA: Health IT Electronic Health  |   |   |   |   |   |   |   |   |
| Record and Innovation Grants       |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > HRSA: Regional Genetic and       |   |   |   |   |   |   |   |   |
| > Newborn Screening Service        |   |   |   |   |   |   |   |   |
| > Collaboratives                   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| HRSA: Telehealth Grants            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Indian Health Service (IHS)        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| IHS: National Data Repository      |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| IHS: Resource and Project          |   |   |   |   |   |   |   |   |
| Management System                  |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| IHS: Telehealth                    |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| National Institutes of Health      |   |   |   |   |   |   |   |   |
| (NIH)                              |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > NIH: Cancer and Biomedical       |   |   |   |   |   |   |   |   |
| > Informatics Grid                 |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > NIH: Clinical Translational      |   |   |   |   |   |   |   |   |
| > Science Awards                   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > NIH: Genome Wide Association     |   |   |   |   |   |   |   |   |
| > Studies Data Sharing Policy      |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > NIH: Health Informatics R & D    |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > NIH: National Network of         |   |   |   |   |   |   |   |   |
| > Libraries of Medicine            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > NIH: Support for Biomedical      |   |   |   |   |   |   |   |   |
| > Informatics Research Training    |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > NIH: Support, Maintenance, &     |   |   |   |   |   |   |   |   |
| > Dissemination of Standard        |   |   |   |   |   |   |   |   |
| > Clinical Vocabularies            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Office for Civil Rights (OCR)      |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > OCR: HIPAA Privacy Rule and      |   |   |   |   |   |   |   |   |
| > Health IT                        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > OCR: Health IT and Health        |   |   |   |   |   |   |   |   |
| > Disparities/Special Needs        |   |   |   |   |   |   |   |   |
| > Populations                      |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Office of the National Coordinator |   |   |   |   |   |   |   |   |
| (ONC)                              |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > ONC: Anti-Fraud Activities       |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > ONC: Certification Commission    |   |   |   |   |   |   |   |   |
| > for Healthcare Information       |   |   |   |   |   |   |   |   |
| > Technology (CCHIT)               |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > ONC: Federal Interdepartmental   |   |   |   |   |   |   |   |   |
| > Health IT Collaborative          |   |   |   |   |   |   |   |   |
| > \[Multi-agency\]                 |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Federal Health Architecture   |   |   |   |   |   |   |   |   |
| (FHA) \[Multi-agency\]             |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Federal Interagency Health IT |   |   |   |   |   |   |   |   |
| Policy Council \[Multi-agency\]    |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Health Information Security   |   |   |   |   |   |   |   |   |
| and Privacy Collaborative (HISPC)  |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Healthcare Information        |   |   |   |   |   |   |   |   |
| Technology Standards Panel (HITSP) |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Nationwide Health Information |   |   |   |   |   |   |   |   |
| Network (NHIN)                     |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Planning AHIC 2.0             |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Secure Messaging Pilot        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Standardized Measures for     |   |   |   |   |   |   |   |   |
| Adoption of EHRs                   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: State Alliance for e-Health   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: State Level Health            |   |   |   |   |   |   |   |   |
| Information Exchange Consensus     |   |   |   |   |   |   |   |   |
| Project                            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Terminology Consensus         |   |   |   |   |   |   |   |   |
| Contract                           |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| ONC: Use Case Development          |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Office of the Secretary (HHS/OS)   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| HHS/OS: Personalized Healthcare    |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| HHS/OS: Value-driven Health Care   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| Substance Abuse and Mental Health  |   |   |   |   |   |   |   |   |
| Services Administration (SAMHSA)   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| SAMHSA: Health IT Initiatives      |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| **Department of Commerce**         |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| National Institute of Standards &  |   |   |   |   |   |   |   |   |
| Technology (NIST)                  |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| NIST: Conformance Testing          |   |   |   |   |   |   |   |   |
| Infrastructure                     |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| NIST: Security Technology          |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| NIST: Conformance and              |   |   |   |   |   |   |   |   |
| Certification Expertise            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| **Department of Defense (DoD)**    |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| DoD: AHLTA                         |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| DoD: Memorandum of Agreement with  |   |   |   |   |   |   |   |   |
| State of Florida                   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| **Department of Veterans Affairs   |   |   |   |   |   |   |   |   |
| (VA)**                             |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| VA: Electronic Health Record       |   |   |   |   |   |   |   |   |
| (VistA, CPRS)                      |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| VA: Personal Health Record         |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| VA: Telehealth                     |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| **Federal Communications           |   |   |   |   |   |   |   |   |
| Commission (FCC)**                 |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| FCC: Rural Health Care Pilot       |   |   |   |   |   |   |   |   |
| Program                            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| **[Social Security Administration  |   |   |   |   |   |   |   |   |
| (SSA)]{.smallcaps}**               |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| SSA: Medical Evidence Request and  |   |   |   |   |   |   |   |   |
| Data Use Prototype                 |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| SSA: NHIN Use Case "Authorized     |   |   |   |   |   |   |   |   |
| Release of Information to a        |   |   |   |   |   |   |   |   |
| Trusted Entity"                    |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| SSA: Personal Health Record Intake |   |   |   |   |   |   |   |   |
| Prototype                          |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| **Multi-Agency Collaborative       |   |   |   |   |   |   |   |   |
| Efforts**                          |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| AHRQ, FDA, & NLM: Data Standards   |   |   |   |   |   |   |   |   |
| Program                            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| DoD & VA: Exchange of Information  |   |   |   |   |   |   |   |   |
| (FHIE, BHIE, CHDR, LDSI)           |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| DoD & VA: Joint EHR Analysis       |   |   |   |   |   |   |   |   |
| Project                            |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| OIG & CMS: Hospital Donation of    |   |   |   |   |   |   |   |   |
| Health IT                          |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| **Other Public-Private Sector      |   |   |   |   |   |   |   |   |
| Initiatives**                      |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| National Quality Forum (NQF)       |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| **Federal Advisory Committees**    |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| National Committee on Vital and    |   |   |   |   |   |   |   |   |
| Health Statistics (NCVHS)          |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| American Health Information        |   |   |   |   |   |   |   |   |
| Community (AHIC)                   |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > AHIC Chronic Care Workgroup      |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > AHIC Confidentiality, Privacy,   |   |   |   |   |   |   |   |   |
| > and Security Workgroup           |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > AHIC Consumer Empowerment        |   |   |   |   |   |   |   |   |
| > Workgroup                        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > AHIC Electronic Health Records   |   |   |   |   |   |   |   |   |
| > Workgroup                        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > AHIC Personalized Healthcare     |   |   |   |   |   |   |   |   |
| > Workgroup                        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > AHIC Population Health and       |   |   |   |   |   |   |   |   |
| > Clinical Care Connections        |   |   |   |   |   |   |   |   |
| > Workgroup                        |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+
| > AHIC Quality Workgroup           |   |   |   |   |   |   |   |   |
+------------------------------------+---+---+---+---+---+---+---+---+

**Appendix C: Descriptions of Initiatives, Programs, and Projects**

The following descriptions serve as background for the many initiatives,
activities, programs, and projects cited throughout the Strategic Plan.
Many of these endeavors advance both goals and their underlying
objectives, while others are more closely related to one of the two
goals. Appendix B lists all of these initiatives and activities, and
highlights which objectives are or have been supported by each
initiative. Each initiative is listed under the department, agency, or
organization that is primarily responsible for sponsoring, funding,
staffing, or leading it. The "boxes" included with the descriptions
highlight the activities to date and agency's contributions in
addressing the goals and objectives of this plan.

**[DEPARTMENT OF HEALTH AND HUMAN SERVICES]{.underline}**

**[AGENCY FOR HEALTHCARE RESEARCH & QUALITY (AHRQ)]{.underline}**

**AHRQ: Health IT Portfolio**

AHRQ has invested in a wide range of projects that form a nationwide
learning laboratory of health care systems, hospitals, physician
practices, research institutes, nursing homes, and other organizations
that are helping to transform clinical practice through health IT.
Technologies such as those used to support electronic health records,
the exchange of health information, and telemedicine hold the potential
to revolutionize everyday clinical care making it better, safer, and
more efficient. Some of the myriad projects funded through AHRQ's Health
IT Portfolio include, but are not limited to:

-   Development of electronic clinical decision support

-   Enhancement of e-prescribing capabilities

-   Development of e-medical records

-   Promotion of personalized healthcare

-   Evaluation of existing health IT projects and grants throughout the
    Department

-   Development and dissemination of information to help improve health
    literacy among the American public

-   Funding for Health Information Exchange - In October 2004 and 2005,
    AHRQ awarded contracts to six states (Connecticut, Utah, Indiana,
    Tennessee, Rhode Island, and Delaware) to support statewide
    demonstration projects on data sharing and interoperability
    activities. The goals of these five year demonstrations are to
    develop organizations that connect local health care providers;
    allow clinicians access to patient information at the point of care;
    demonstrate measurable improvements in the areas of quality, safety,
    efficiency, and effectiveness of health care for patients and
    populations on a state or regional level; and to identify successful
    strategies for the sustainability of health information exchanges.
    Each state can develop its own technical, business, and governance
    structures.

-   National Resource Center for Health IT - The National Resource
    Center for Health Information Technology (the NRC) is a central
    national source of information and assistance to help the nation
    embrace the power and efficiency of health information technology.
    Currently administered by the National Opinion Research Center, the
    NRC provides direct technical assistance and consulting services to
    AHRQ projects and grantees involved in developing, testing, and
    using health IT applications, with a particular focus on addressing
    challenges to health IT implementation in rural and small community
    settings. The NRC has also supported key efforts at other Federal
    agencies including CMS, HRSA, and IHS. NRC is helping to build the
    nation\'s capacity across health care settings for the effective use
    of health IT. In addition, the NRC serves as a link between the
    health care community at large and the researchers and experts who
    concentrate on health IT. As the central repository for lessons
    learned from AHRQ\'s health IT initiative, the NRC encourages
    adoption of health IT by disseminating the latest tools, best
    practices, and research results from this unique real-world
    laboratory to the broader health care community and to the public at
    large.

**AHRQ: United States Health Information Knowledgebase**

The United States Health Information Knowledgebase (USHIK) is a health
metadata registry funded and directed by the Agency for Healthcare
Research and Quality. USHIK provides and maintains a metadata registry
of health information data element definitions, values and information
models that enable browsing, comparison, synchronization, and
harmonization within a uniform query and interface environment. USHIK is
populated with the data elements and information models of Standards
Development Organizations (SDOs) and other health care organizations in
such a way that public and private organizations can harmonize
information formats with health care standards. USHIK also contains data
element information for government initiatives that support the use and
implementation of data standards such as the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) and the Consolidated
Health Informatics (CHI) initiative.

> *Progress on Plan Objectives*
>
> AHRQ has invested more than \$216 million in grants and contracts to
> organizations in 48 states stimulating investment in the exchange of
> health information, with emphasis on rural and underserved areas. AHRQ
> has funded six states to demonstrate state-wide interoperability and
> data sharing.
>
> The National Resource Center currently provides technical assistance
> to over 200 AHRQ grantees and contractors, six state and regional
> demonstration projects promoting the exchange of health information,
> and 33 states and one territory working on a Health Information
> Security and Privacy Collaboration.
>
> USHIK is built on ISO standard 11179. USHIK can produce columns of
> attributes for each data element and can present comparisons of
> similar data elements from different standards organizations. USHIK
> enables analyses of compatibility/incompatibility and provides a tool
> for data element harmonization. In 2007 data elements from the
> bioterrorism use case were added to the registry.

**[ASSISTANT SECRETARY FOR PLANNING & EVALUATION (ASPE)]{.underline}**

**ASPE: Health Information Activities**

The Assistant Secretary for Planning and Evaluation (ASPE) advises the
Secretary of HHS on policy development in health, disability, human
services, data, and science, and provides advice and analysis on
economic policy.  Integral to this role, ASPE conducts research and
evaluation studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives related to promoting the adoption and
implementation of health IT.

> *Progress on Plan Objectives*
>
> ASPE has funded a number of studies to help inform policies related to
> health IT such as an analysis of health IT costs and benefits, an
> analysis of consumer control of personal electronic health
> information, an economic assessment of small physician practices'
> adoption of electronic medical records, studies examining the exchange
> of health information for persons receiving post-acute and long-term
> care services, and work cooperatively undertaken through the CHI
> initiative resulting in CHI patient assessment and disability
> standards accepted by the Secretary. ASPE is currently funding several
> projects to help inform and promote the Secretary's health IT agenda,
> such as analyzing and modeling the factors associated with successful
> EHR adoption in physician offices, supporting the specification of the
> HL7 EHR-S Functional Profile for Nursing Homes, evaluating a CMS pilot
> for the use of EHRs by the Medicare fee-for-service population, and
> application of recognized CHI standards to federally-required
> assessments.

**[ASSISTANT SECRETARY FOR PREPAREDNESS & RESPONSE (ASPR)]{.underline}**

**ASPR: Homeland Security Presidential Directive 21**

On October 18, 2007, the White House released Homeland Security
Presidential Directive 21 (HSPD-21). HSPD-21 calls on the HHS Secretary
to establish an operational national epidemiologic surveillance system
for human health that is predicated on state, regional, and
community-level capabilities and creates a networked system for two-way
information flow between federal, state, tribal, and local government
public health authorities and clinical health care providers. To the
extent feasible, the system should be built using electronic health
information systems and integrate its data into a national
bio-surveillance common infrastructure.

HSPD-21 calls for the creation of cabinet-level Public Health and
Medical Preparedness Task Force by February 2008. The Task Force, which
has been created, is chaired by the HHS Secretary.

The HHS Secretary, in coordination with the Secretaries of Defense,
Veterans Affairs, and Homeland Security, is working to establish an
Epidemiologic Surveillance Federal Advisory Committee by July 2008.  The
Advisory Committee will also include representatives from state and
local public health agencies and appropriate private sector health care
entities to ensure that the federal government is properly enabling
state and local public health surveillance capabilities.

**ASPR: Pandemic and All-Hazards Preparedness Act**

The Pandemic and All-Hazards Preparedness Act (PAHPA) calls for the
Secretary to establish a near real-time electronic nationwide public
health situational awareness capability through an interoperable network
of systems. Once established, this capability will allow public health
officials to share data and information to enhance early detection of
and rapid response to potentially catastrophic infectious disease
outbreaks and other public health emergencies. In addition, PAHPA calls
for the design of a system to link existing State verification systems
to create a single national interoperable network for the purpose of
verifying the credentials and licenses of health care professionals
during a public health emergency. PAHPA also calls for an inventory of
telehealth initiatives in existence on the date of enactment of PAHPA,
to include the identification of methods to expand and interconnect
health information networks; to evaluate ways to prepare for, monitor,
respond to, and manage the events of a public health emergency through
the enhanced use of telehealth technologies; and to promote greater
coordination among existing Federal interagency initiatives.

> *Progress on Plan Objectives*
>
> Pursuant to Presidential Directive 21: the Cabinet Level Task Force
> has been established and is developing the implementation plan for the
> Public Health and Medical Preparedness Strategy. HHS, DoD and VA are
> working together to establish the Epidemiological Surveillance Federal
> Advisory Committee.
>
> Consistent with PAHPA, the Secretary of HHS has delegated
> responsibility to ASPR. ASPR has completed the telehealth initiatives
> inventory and is working with sister agencies and states to develop
> the interoperable network of systems for situational awareness
> capability.

**[CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)]{.underline}**

**CDC: BioSense**

BioSense is a national program intended to improve the nation's
capabilities for conducting near real-time biosurveillance, enabling
health situational awareness through access to existing data from health
care organizations across the country. The primary objective is to
expedite event recognition and response coordination among federal,
state, and local public health and health care organizations by
providing each level of public health access to the same data at the
same time.

**CDC: Epi-X**

Epi-X is a web-based communications network created by the CDC for
public health professionals. Through Epi-X, CDC officials, state and
local health departments, poison control centers, and public health
professionals can access and share health surveillance information in a
secure platform. The 4,200 users receive notifications on breaking
public health news as they occur. These real time public health alerts,
reports, discussions, and comments are continuously moderated by medical
epidemiologists and clinical laboratory professionals at CDC. Epi-X is
accessible only to public health officials designated by each regional
agency. These experts engage in rapid outbreak reporting, peer-to-peer
consultation, postings and discussions about disease outbreaks and other
public health events that may involve multiple jurisdictions.

**CDC: National Healthcare Safety Network**

Launched by the CDC in 2005, the National Healthcare Safety Network
(NHSN) was created to integrate and supersede three existing
surveillance systems, the National Nosocomial Infections Surveillance
System, the Dialysis Surveillance Network, and the National Surveillance
of Healthcare Workers. NHSN facilitates voluntary reporting of health
care-associated infection information and aggregates the data for use by
health care facilities and public health agencies through its two
surveillance areas: patient safety and health care personnel safety. The
goal is to create a knowledge system for accumulating, exchanging, and
integrating relevant information on adverse events associated with
health care delivery. NHSN will soon allow for the collection of health
care worker influenza vaccination data, multi-drug resistant organism
data, central line insertion practices, and high-risk patient influenza
vaccination data.

**CDC: Public Health Informatics Fellowship Program**

The CDC Public Health Informatics Program is a two-year applied training
program for professionals interested in the application of information
and computer science and technology to public health practice, research
and learning. Applicants to the program typically have backgrounds in
public health and information and computer science and technology, as
well as related domains (engineering, medicine, nursing, library
science). Since 1996, the program has produced 58 graduates, 70 percent
of which have remained working in public health. The program also offers
technical assistance (Info-Aids) to an increasing number of states.

**CDC: Public Health Information Network**

In 2002, CDC launched the Public Health Information Network (PHIN)
initiative to improve the capacity of public health agencies to use and
exchange information electronically by promoting the use of standards
and defining technical requirements. The standards and technical
requirements are determined by best practices related to efficient,
effective, and interoperable public health information systems that
support both routine public health activities and emergency preparedness
and response.

**CDC: Public Health Preparedness Systems**

CDC distributes resources to support public health preparedness
activities, ensures that electronic and other systems are in place to
monitor performance and manage accountability, and coordinates the
communication efforts among key stakeholders. CDC also oversees the
administration of the Cooperative Agreement for Public Health Emergency
Preparedness to state and local health departments.

> *Progress on Plan Objectives*
>
> BioSense has begun focusing on the following:

-   Catastrophic public health emergencies

-   Enhancing biosurveillance capabilities across cities and states

-   Data feeds from acute care hospitals to Federal, state and local
    public health departments

-   Evaluating cost-effectiveness of different configurations for
    connecting health care information sources

-   Field testing the biosurveillance Minimum Data Set

> Epi-X has supported 6,700 reports related to local and national
> responses to terrorism, SARS, Hurricane Katrina, and influenza
> surveillance.
>
> In 2005, CDC initially opened NHSN enrollment to a limited number of
> facilities. In 2007, CDC launched a national open enrollment for
> hospitals and outpatient hemodialysis centers.
>
> Current PHIN activities involve educating members of the PHIN
> community, evaluating best practices, encouraging policy discussion,
> and creating both vocabulary and messaging standards.
>
> The Centers for Public Health Preparedness (CPHP) was created to
> strengthen terrorism and emergency preparedness. CPHP major activities
> include education and training and activities that are needed for the
> general support of preparedness education, outreach, partnership, and
> program evaluation.

**[CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)]{.underline}**

**CMS: Beneficiary Information Services**

One of CMS' priorities, as indicated in its most recent Strategic Plan,
is to empower beneficiaries to make more informed decisions about their
health and health care. To support this priority, CMS has implemented an
online Medicare account management tool for beneficiaries, the Medicare
Beneficiary Portal, and has begun to explore the use of personal health
records for beneficiaries.

**CMS: EHR Adoption Demonstration**

CMS is implementing a new demonstration project in which up to 1,200
small to medium sized primary care practices in up to 12 different
locations will be eligible to receive additional Medicare payments for
using EHRs to improve care. Under the demonstration, primary care
doctors who use certified EHRs to coordinate and provide care to
Medicare beneficiaries and achieve certain clinical quality measures
will be eligible to earn up to several thousand dollars per year in
incentive payments. By design, the demonstration will be budget neutral
by requiring that the associated costs be offset by savings resulting
from more efficient health care delivery.

**CMS: E-Prescribing Efforts**

The Medicare Prescriptions Drug, Improvement, and Modernization Act of
2003 (MMA) (Pub.L. No. 108-173) directed the Secretary to promulgate
uniform standards for the electronic transmission of prescription and
certain other information for covered Part D drugs prescribed for
Medicare Part D eligible individuals. CMS adopted a set of foundation
standards for e-prescribing under Medicare Part D, worked in
collaboration with AHRQ to pilot test additional e-prescribing
standards, published a required report to Congress on the results of
that pilot, and issued a final rule that will require the use of the
successfully tested standards and the National Provider Identifier in
e-prescribing Part D covered drugs for Part D eligible individuals under
specified circumstances.

**CMS: HIPAA Security Rule**

CMS administers the Security Rule, promulgated pursuant to the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), which
establishes security protections for electronic protected health
information. With delegated authority to implement and enforce the HIPAA
Security requirements, CMS regularly issues guidance in the form of
educational papers, FAQs, enforcement statements, and other documents,
to assist the industry in complying with the HIPAA Security Rule
requirements.

**CMS: International Classification of Diseases (ICD-10)**

International Classification of Diseases (ICD) code sets were developed
for statistical reporting of worldwide mortality data. Currently, the
United States uses ICD-10 (tenth version) codes for mortality reporting
and uses ICD-9 (ninth version) for its morbidity reporting. The tenth
version of the code sets vastly expands the number and complexity of
both diagnosis and procedure codes, making the codes more precise and
comprehensive. Consequently, this increased granularity and precision
would increase the quality of information collected and could have many
potential benefits to the US health care system.

**CMS: Medicaid Information Technology Architecture**

The Medicaid Information Technology Architecture (MITA) is an IT
initiative intended to foster and stimulate an integrated business and
IT transformation across the Medicaid enterprise. The overall goal of
the MITA project is to facilitate an improved process for design and
implementation of information systems that improves the quality and
efficiency of health care delivery, which in turn will improve
beneficiary and population outcomes. The overall goal of the MITA
project is to establish a national framework for enabling technologies
and processes that support improved program administration for the
Medicaid enterprise and stakeholders dedicated to improving health care
outcomes and administrative procedures for Medicaid beneficiaries. MITA
guidelines will ultimately serve as the basis for states' requests for
federal financial participation for the Medicaid Management Information
System (MMIS).

**CMS: Medicaid Reimbursement for Telehealth Services**

States may decide to reimburse Medicaid services provided through
telemedicine applications. Telemedicine is not formally defined for the
Medicaid program and Medicaid law does not recognize telemedicine as a
distinct service; however, states can reimburse services given through
telemedicine to supplement or enhance the more traditional ways of
providing medical care.

[]{.mark}

**CMS: Medicaid Transformation Grants**

In 2005, the Deficit Reduction Act authorized \$150 million in new grant
funds to states for the adoption of innovative methods to improve
effectiveness and efficiency in providing medical assistance under
Medicaid. CMS encouraged states to look at how health IT and the
exchange of health information could be leveraged to improve Medicaid
services (e.g., reduce medical errors through the implementation of
EHRs, clinical decision support tools, or eRx.) The funds also could be
used for other Medicaid improvement programs, including efforts to
reduce Medicaid fraud and abuse.

> *Progress on Plan Objectives*
>
> CMS launched the Medicare Beneficiary Portal in 2004. Currently, the
> Medicare Beneficiary Portal offers administrative information, such as
> claims, eligibility, and benefit structure. Some clinical services are
> also available. In June 2007, CMS launched an 18-month pilot project
> to examine PHR use by Medicare beneficiaries. CMS will determine the
> features that are most attractive to beneficiaries, identify the
> minimum content and functionality for the PHR tool, and assess the
> best methods for outreach and education to encourage adoption and
> ongoing use.
>
> The CMS EHR Adoption Demonstration was announced on October 30, 2007.
> The five-year demonstration is projected to start recruiting practices
> in late summer 2008 and begin operations in 2009.
>
> In 2005, CMS published a final rule establishing three "foundation"
> eRx standards that cover certain transactions between prescribers and
> Medicare Part D sponsors as well as dispensers and Medicare Part D
> sponsors, and eligibility queries between dispensers and Medicare Part
> D sponsors. In 2006, CMS initiated a pilot project in five locations
> to test six initial standards for E-prescribing. In 2007 CMS published
> a proposed rule consistent with the results of the pilot that proposed
> to adopt additional e-prescribing standards. CMS published a final
> rule in April 2008 that will require the use of the successfully
> tested standards and the NPI in e-prescribing Part D covered drugs for
> Part D eligible individuals.
>
> CMS' activities related to Health IT include:
>
> \- Participation on the American Health Information Community
> Workgroups for
>
> Confidentiality, Privacy, and Security and Consumer Empowerment;
>
> \- Staff participation on the National Committee on Vital and Health
> Statistics
>
> (NCVHS) Standards and Security Subcommittee;
>
> \- Collaboration with ONC in its efforts to develop a confidentiality,
> privacy, and security framework for exchange of electronic health
> information, including participation on the ONC-sponsored inter-agency
> health IT policy council;
>
> \- Collaboration with OCR on security and privacy initiatives and
> HIPAA enforcement;
>
> \- Collaboration with the National Institute of Standards and
> Technology on technical guidance;
>
> \- Collaboration with outside stakeholder groups to develop
> appropriate education on the Security Rule and its implementation.
>
> To test the technical feasibility of using ICD-10 for HIPAA covered
> transactions, ICD-10 was tested by CMS's Clinical Data Abstraction
> Centers. CMS is studying the cost and time necessary for converting
> its own systems and is evaluating alternatives to support Industry
> migration to ICD-10 if and when a rule is proposed and finalized.
>
> Many states reimburse Medicaid services made available through
> telemedicine to improve access to specialists for rural communities
> and to reduce transportation costs. Most of these states reimburse
> physician consultations provided through interactive video
> teleconferencing.
>
> In 2007, CMS awarded Medicaid transformation grants to 34 states and
> one territory, totaling \$150 million, the majority of which were for
> health IT-related initiatives. Medicaid transformation grants were
> limited to FY's 2007 and 2008.

**[FOOD & DRUG ADMINISTRATION (FDA)]{.underline}**

**FDA: Sentinel Network**

The Food and Drug Administration is creating a national, integrated,
electronic system for monitoring medical product safety. This system
will be developed and implemented in stages, and will ultimately enable
FDA to access the capabilities of existing, remote data systems to
augment the Agency's current capability. Such a system will enable FDA
to query distributed data sources quickly and securely for relevant
de-identified product safety information.

As envisioned, the system would facilitate targeted queries, within the
bounds of established privacy and security safeguards, across remote
systems. The Sentinel Network will build on existing systems and data,
to the extent practicable, rather than create a new system. The system
will follow scientific principles of surveillance, using health IT
standards harmonized by HITSP, recommended by the AHIC to the HHS
Secretary, and recognized by the HHS Secretary, as well as ensure the
protection of privacy and security of personal health information.

**FDA: Structured Product Labeling**

Structured Product Labeling (SPL) is part of the FDA initiative to
improve patient safety through better access to product information. It
is an electronic file in XML format that includes both the content of
the labeling that accompanies the drug and specific data elements
describing the product including the National Drug Code and Unique
Ingredient Identifiers (UNII). The latest release of SPL includes
products other than drugs, such as medical devices.

> *Progress on Plan Objectives*
>
> The public meeting on the Sentinel Network yielded consensus to build
> upon existing data resources/programs in both the public (CMS and
> Medicare) and private (HMO Research Network) sector.
>
> Currently, FDA makes SPL for approved human prescription drugs
> available for download for no cost through the National Library of
> Medicine DailyMed web site. FDA plans to make SPL available for all
> drugs marketed in the United States. SPL is a Health Level Seven
> standard accredited by the American National Standards Institute.

**[HEALTH RESOURCES SERVICES ADMINISTRATION (HRSA)]{.underline}**

**HRSA: *Connections* Project**

Through a cooperative agreement with HRSA, the Public Health Informatics
Institute has established several activities to facilitate communities
of practice. A community of practice involves the collaboration of a
group of people with a common interest who work together over an
extended period of time to share ideas and find solutions to a problem.
*Connections* serves as a community of practice, providing technical
assistance to public health agencies as they develop strategies and
activities to integrate information systems essential to improving the
health of children. *Connections* was launched in June 2001.
Participants collaborate on issues specific to the integration of early
child health information systems, including newborn screening, newborn
dried blood spot screening, vital records, immunization registries, and
lead screening programs.

**HRSA: Rural Hospital Flexibility Grant Program -- FLEX**

Under the HRSA-supported Rural Hospital Flexibility Grant Program, known
as FLEX, 16 Health Information Technology Network Implementation grants
were awarded to states to help critical access hospitals (CAHs) set up
EHRs and other health information technology. Funds will enable CAHs,
which receive Medicare reimbursement for acute inpatient and outpatient
services, to improve monitoring of patient information and increase the
safety, quality and efficiency of rural health services.

**HRSA:** **Health IT Electronic Health Record and Innovations Grants**

HRSA has awarded over \$30 million in grants to help networks of health
centers prepare to adopt and implement Electronic Health Records (EHR)
and other health information technology (health IT) innovations. EHRs,
critical tools in improving the quality of care, provide health care
professionals the ability to monitor and analyze health information for
their patients.  EHRs are widely considered to be essential in improving
the safety and quality of health care delivery and cutting waste and
duplication of care.  The grants fund the purchase, planning and
implementation of EHRs and other health IT innovations such as
electronic prescribing, physician order entry, personal health records,
community health records, exchange of health information, smart cards,
and interoperability with outside partners. 

**HRSA: Regional Genetic and Newborn Screening Service Collaboratives**

The Regional Collaborative Program consists of seven Regional Genetic
and Newborn Screening Collaboratives (RCs) and a National Coordinating
Center (NCC). There are several projects that the RCs and the NCC for
the RCs have undertaken. The NCC is assessing various aspects of the
integration of clinical and laboratory medical genetics into electronic
health systems for the integration and adoption of genetic information
in the electronic health record system

**HRSA Telehealth Grants**

The Health Resources and Services Administration (HRSA) offers a number
of telehealth grant programs). 

The Telehealth Network Grant Program (TNGP) awards 3-year grants to
networks of providers to demonstrate how telehealth technologies can be
used to: expand access to, coordinate, and improve the quality of health
care services; improve and expand the training of health care providers;
and/or expand and improve the quality of health information available to
health care providers, patients, and their families. In 2006, HRSA
initiated a special focus on evaluating the costs and effectiveness of
tele-homecare and home monitoring services through three 3-year grants.

HRSA supports six Telehealth Resource Centers under a grant program to
assist health care organizations, networks, and providers in the
implementation of cost effective telehealth programs to serve rural and
medically underserved areas and populations.

The Licensure Portability Grant Program (LPGP) provides support for
State professional licensing boards to carry out programs under which
state licensing boards cooperate to develop and implement State policies
and systems that will reduce statutory and regulatory barriers to
telemedicine.

> *Progress on Plan Objectives*
>
> Ongoing *Connections* activities include: defining the business
> processes of the newborn dried blood spot screening (NDBS) system in
> providing a blue-print for developing information systems that support
> the information needs of all the stakeholders involved in the overall
> NDBS system, and developing a Health Level 7 implementation guide for
> the electronic transmission of NDBS results in compliance with
> national standards.
>
> Under FLEX, 16 Health Information Technology Network Implementation
> grants were awarded to states to help CAHs set up electronic health
> records and other health information technology. Funds will enable
> CAHs, which receive Medicare reimbursement for acute inpatient and
> outpatient services, to improve monitoring of patient information and
> increase safety, quality and efficiency of rural health services.
>
> In August, 2007 HRSA announced \$31.4 million in health IT Electronic
> Health Record and innovations grants to help health centers prepare to
> adopt and implement EHRS and other health information technology
> innovations. Of the total, \$8 million was earmarked for planning
> activities, and the remainder was for implementation and support for
> EHRs at health centers and in networks that link multiple health
> center grantees.
>
> Four regional genetic and newborn screening collaboratives are
> participating in collaborative studies using health information
> technology and information exchange including the creation and use of
> regional and national information systems designed to monitor heath
> outcomes of infants and children identified with heritable disorders
> in newborn screening programs, evaluate newborn screening program
> performance and valuate treatment protocols.
>
> HRSA is providing funding to 16 grantees across the nation to develop,
> implement, and evaluate telehealth programs in a variety of settings
> from primary care clinics, nursing homes, and hospitals to
> individuals' homes. Five centers distributed across the country have
> been awarded Telehealth Resource Center Grants to provide multistate
> services through a network of regional centers that provide technical
> assistance services locally but collaborate nationally.

**[INDIAN HEALTH SERVICES (IHS)]{.underline}**

**IHS: National Data Repository**

The purpose of the Indian Health Service's national data repository,
National Patient Information Reporting System (NPIRS), is to provide a
broad range of clinical and administrative information to managers at
all levels of the Indian health care system to allow them to better
manage individual patients, local facilities, and regional and national
programs. NPIRS has recently completed an upgrade to a new,
state-of-the-art, enterprise-wide national data warehouse (NDW) system.
This system provides a more accurate, timely, and broader scope of
information to clinical and administrative managers throughout the
Indian health system.

**IHS: Resource and Patient Management System**

The Resource and Patient Management System (RPMS) is a componentized
electronic health care information system that provides Practice
Management functions for IHS-direct, tribal and urban Indian health care
delivery facilities throughout the United States. RPMS provides
accurate, timely, and comprehensive clinical and administrative
information to local health care providers and program managers and
provides administrative information at the regional and national levels.
The ultimate purpose of the RPMS is to improve the availability of
medical information on American Indian and Alaska Native patients,
thereby improving the diagnoses, decision making, and health care
recommendations of IHS physicians and other IHS health care providers.

The Clinical Reporting System (CRS) is an RPMS software application
designed for national reporting as well as local and Area monitoring of
clinical performance measures. CRS produces on demand from local RPMS
databases a printed or electronic report for any or all of over 300+
clinical performance measures, representing 55 clinical topics. CRS is
intended to eliminate the need for manual chart audits for evaluating
and reporting clinical measures that depend on RPMS data.

iCare is a component of the RPMS that presents diverse patient data in
one user-friendly view. IHS initiated this population health care
management project to provide an easy-to-use tool with multiple uses to
a wide variety of wide variety of providers. iCare also supports
critical care coordination capabilities.

**IHS: Telehealth**

The IHS telehealth program supports a broad range of activities in four
strategic directions: innovation, resource/infrastructure development,
business modeling, and collaboration. These activities occur in
partnership with IHS Areas and individual IHS/tribal facilities already
engaged or planning to be engaged in telehealth service delivery.
Specifically, the telehealth program works to:

-   Support national Indian health initiatives and priorities;

-   Identify and disseminate information on emerging telehealth
    applications and experience;

-   Provide on-site and remote consultation and support to facilities
    and programs in the 12 IHS Areas;

-   Propose/implement new models of service delivery based on
    telehealth;

-   Develop business modeling specific to telehealth sustainability;

-   Enhance distance education via emerging tele-education tools;

-   Extend collaborations specific to telehealth service delivery among
    Indian health stakeholders and with state, federal, university, and
    other health organizations.

> *Progress on Plan Objectives*
>
> NPIRS (National Patient Information Reporting System) is the national
> data warehouse (NDW) for IHS statistical heath care data on patient
> registration and visit encounters occurring at either IHS facilities
> or contracting facilities that provide care. NPIRS Monthly exports to
> the NDW typically contain data from over 2.2 million patient
> encounters at approximately 293 IHS and Tribal health care facilities
> in 35 states and supports enhance care-coordination capabilities
>
> RPMS, CRS and iCare enable interoperability of data and support
> automated quality care reporting and population health monitoring.
>
> Telehealth tools play an important role in the evolving model of
> service delivery for Indian health care. These tools support access to
> multi-specialty services, consultation, and training for facilities
> and communities in all 12 Areas of the Indian Health Service (IHS).
> Leading clinical telehealth applications include tele-radiology,
> tele-cardiology, tele-behavioral health, tele-dermatology, and
> tele-opthalmology.

**[NATIONAL INSTITUTES OF HEALTH (NIH)]{.underline}**

**NIH: The Cancer Biomedical Informatics Grid (CaBIG)**™

The National Cancer Institute\'s (NCI) caBIG™ (cancer Biomedical
Informatics Grid™) initiative serves as the cornerstone of NCI's
biomedical informatics efforts to transform cancer research into a more
collaborative, efficient, and effective endeavor, and establish
interoperability between research and care. The infrastructure, tools,
and policies of caBIG™-- including activities around data sharing and
security--- could serve as a model to support applications beyond the
cancer community, and the initiative collaborates with health and
biomedical information technology efforts in other domains and other
countries. The underlying service oriented infrastructure that supports
caBIG™ is referred to as caGrid. Driven primarily by scientific use
cases from the cancer research community, caGrid provides the core
enabling infrastructure necessary to compose the grid of caBIG™. CaGrid™
provides the technology that enables collaborating institutions to share
information and analytical resources efficiently and securely, and
allows investigators to easily contribute to and leverage the resources
of a national-scale, multi-institutional environment.

**NIH: Clinical Translational Science Awards**

A national consortium, funded through Clinical and Translational Science
Awards (CTSAs), is focused on transforming clinical and translational
research to enable researchers to more quickly and efficiently develop
new patient treatments. One goal of the program is widespread
utilization of health and research information technology to increase
understanding of disease, facilitate clinical studies and trials, and
advance adoption of effective treatments. CTSA training programs for
development of new clinical and translational researchers will
incorporate knowledge of informatics.

**NIH: Genome Wide Association Studies Data Sharing Policy**

The NIH is interested in advancing the use of data obtained through
genome-wide association studies (GWAS) to identify common genetic
factors that influence health and disease.  The goal of the GWAS policy
is to facilitate broad and consistent access to NIH-supported GWAS data
in order to speed the translation of basic genetic research into
therapies, products, and procedures that benefit the public health.  The
full value of GWAS to the public can be realized only if the resulting
datasets are made available as rapidly as possible to a wide range of
scientific investigators by means of information technology under
conditions that provide appropriate protections for research
participants and respect the conditions under which they consented to
participate.

**NIH: Health Informatics R&D**

NIH's informatics research grants and contracts and its intramural
research programs have supported pioneering research and development in
bioinformatics, artificial intelligence in medicine, clinical decision
support, biomedical ontology, imaging, electronic medical records,
regional health data exchange (including both health care and public
health organizations), health applications of advanced
telecommunications networks, automated biosurveillance, and emergency
management systems.

**NIH: National Network of Libraries of Medicine**

The National Network of Libraries of Medicine is comprised of 8 Regional
Medical Libraries, 120 "resource libraries" primarily at schools of the
health sciences, and nearly 6,000 hospital libraries, public libraries,
and community-based organizations that serve as health information
portals. Under the direction of NIH's National Library of Medicine, the
electronic network is an efficient way to ensure that published research
results are easily and efficiently accessible by scientists, health
professionals, and the public. Member institutions staff exhibits at
public and professional meetings, conduct orientation and training
courses, and develop partnerships with community organizations to
improve access to health information for underserved populations. The
Network is a key player in the MedlinePlus "Go Local" feature, which
provides information about local health and emergency services as an
adjunct to the nationally applicable health information in MedlinePlus,
available online at http://www.nlm.nih.gov/medlineplus/.

[]{.mark}

**NIH: Support for Biomedical Informatics Research Training**

Informatics requires knowledge of a biological, medical, or public
health domain as well as computer and information sciences, statistics
or mathematics, engineering, and human behavior. Developing a cadre of
cross-trained researchers is especially important as advancement of
health care and biomedical research requires investigators who
understand biomedicine as well as knowledge representation, decision
support, translational research, and human-computer interface.

**NIH: Support, Maintenance, and Dissemination of Standard Clinical
Vocabularies**

As the designated HHS coordinating body for clinical terminology
standards, the National Library of Medicine supports the development,
enhancement, coordination, and distribution of clinically specific
vocabularies to facilitate the exchange of clinical data and improve
retrieval of health information. NLM funds the ongoing maintenance of
LOINC (Logical Observation Identifiers, Names, Codes), pays for a
U.S.-wide license for the use of SNOMED CT (Systematized Nomenclature of
Medicine -- Clinical Terms) serves as the U.S. member of the recently
formed International Health Terminology Standards Development
Organization, and is the developer of the RxNorm clinical drug
vocabulary. These three vocabularies are available separately and also
within the Unified Medical Language System (UMLS), where they are
integrated in a common format with more than 100 other biomedical and
health terminologies and classifications. Data from the UMLS provide a
foundation for the caBIG Enterprise Vocabulary Server, which provides
vocabulary services tailored for the research community. NLM leads
efforts to align clinical vocabularies with messaging standards and to
map clinically specific vocabularies to administrative code sets, and
works with many other government and private organizations to promote
use of standard terminologies. http://www.nlm.nih.gov/healthit.html

*Progress on Plan Objectives*

The caBIG™ community has developed and released bioinformatics tools and
capabilities that span the entire continuum of clinical research,
pathology, imaging, and genomics and are being deployed at 43 major
cancer centers. Over a dozen community cancer centers are working toward
interoperable electronic health records to enable information exchange
with caBIG compatible tools. CaGrid 1.1 released in September, 2007,
includes important security features. CaBIG provides a metadata
registry, terminology server, and many open source software tools useful
in the development of research and health information systems. The caBIG
website provides access to current inventory of open source caBIG tools
and infrastructure (https://cabig.nci.nih.gov/), along with information
and tools to assist in achieving and certifying caBIG compatibility.

The Clinical Translational Science Awards consortium is currently
comprised of 24 academic health centers in 18 states and ultimately will
link 60 institutions together to support clinical and translational
science.

The NIH data sharing policy for Genome Wide Association Studies was
released in August 2007 and its implementation guidance in November
2007, providing useful models for policy development in other population
health arenas.

NIH grants and contracts support significant research that informs how
health information is gathered, generated, stored, protected, and made
available when and where it is needed to improve decision-making and
translate research results into improved clinical practice.

The National Network of Libraries of Medicine, supported by the National
Library of Medicine has successfully provided access to health
information for clinicians and patients displaced by disasters and rapid
backup and assistance for affected health science libraries. The Network
is the backbone of NLM's strategy to promote effective use of libraries
and librarians in local, state, and national disaster preparedness and
response efforts. http://www.nlm.nih.gov/network.html.

The National Library of Medicine supports biomedical informatics
research training through 20 university-based training centers with
approximately 250 pre-doctoral and post-doctoral trainees across the
U.S. In 2009, three other NIH institutes provided funds to support
additional trainees. http://www.nlm.nih.gov/ep/GrantTrainInstitute.html.

NIH/NLM has played a key role in establishing stable support and
distribution mechanisms for key clinical terminology standards. In 2007,
NLM helped to establish the International Health Terminology Standards
Development Organization, which assumed ownership of SNOMED CT in April
2007, with membership and licensing terms favorable to U.S. interests.

CMS and NIH recently signed a memorandum of understanding under which
NLM is providing technical advice on design and planning and tailored
vocabulary subsets to support the implementation of the Continuity
Assessment Record & Evaluation (CARE) to promote compliance and
compatibility health data standards, including LOINC, RxNorm, and HL7.

The "Go Local" links on the Medline Plus website's health topic pages
are linked to information about health services in local geographic
areas including hospitals, physician offices, nursing homes, support
groups, and health screening providers. "Go Local" now covers geographic
areas where more than two-thirds of the U.S. population resides.

**[OFFICE FOR CIVIL RIGHTS]{.underline}**

**OCR: HIPAA Privacy Rule and Health IT**

OCR administers the Privacy Rule, promulgated pursuant to the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), which
establishes a federal floor of privacy protections and individual rights
with respect to certain individually identifiable health information.
OCR provides expertise to assist the Department and industry in building
upon the baseline protections HIPAA provides to establish a privacy
framework appropriate for exchange of electronic health information
nationwide. OCR activities include:

-   Participation on the American Health Information Community (AHIC)
    Workgroups for Confidentiality, Privacy, and Security, and Consumer
    Empowerment;

-   Staff participation on the National Committee on Vital and Health
    Statistics (NCVHS) Privacy and Confidentiality Subcommittee;

-   Collaboration with ONC in their efforts to develop a
    confidentiality, privacy, and security framework for electronic
    exchange of health information, including participation on the
    ONC-sponsored inter-agency health IT policy council;

-   Collaboration with CMS on e-prescribing and other CMS health IT
    programs and initiatives; and

-   Collaboration with outside stakeholder groups to develop appropriate
    data stewardship and other principles.

OCR also provides education and guidance to address misconceptions and
misapplications of the Privacy Rule, and to explain how the HIPAA
Privacy Rule applies to the electronic exchange of health information in
various circumstances.

**OCR: Health IT and Health Disparities/Special Needs Populations**

OCR is an active participant in the Department's efforts to ensure that
the benefits of health IT reach underserved and special needs
populations and help to improve access to care and reduce health
disparities.

> *Progress on Plan Objectives*
>
> OCR led a national teleconference explaining how the HIPAA Privacy
> Rule applies to Personal Health Records (PHRs). OCR participated in
> the development of Health IT recommendations from the AHIC
> Confidentiality, Privacy, and Security, and Consumer Empowerment
> Workgroups, as well as from the National Committee on Vital and Health
> Statistics.
>
> OCR participates in the Consumer Empowerment Workgroup, including its
> Special Populations Subgroup, which is working to identify and address
> health IT issues unique to special populations, such as persons with
> disabilities, underserved residents of rural areas, and racial and
> ethnic minorities, to maximize their access through personal health
> information. OCR is a member of the HHS Workgroup on Health IT and
> Underserved Populations, led by the HHS Office of Minority Health,
> which seeks to ensure that Departmental health IT activities address
> and do not exacerbate health disparities.

**[OFFICE OF THE NATIONAL COORDINATOR (ONC)]{.underline}**

**ONC: Anti-Fraud Activities**

In late 2006, ONC contracted with RTI International to develop
recommendations for functional requirements for EHRs that would enhance
data by reducing the incidence of improper payment and assisting in
fraud management. The recommendations were developed by a team of
experts and reviewed by more than 75 health care industry leaders,
practitioners, and organizations. RTI researchers also worked with
American Health Information Management Association and leading
statistical software companies SAS and SPSS.

**ONC: Certification Commission for Healthcare Information Technology**

The Certification Commission for Healthcare Information Technology
(CCHIT) is a certification body for EHRs and their networks that has
been recognized by the Secretary. Formed in July 2004 by the American
Health Information Management Association, the Health Information
Management and Systems Society, and the National Alliance for Health
Information Technology, CCHIT was established as an independent,
nonprofit organization. In October 2005, CCHIT was awarded a contract by
the U.S. Department of Health and Human Services (HHS) to develop and
evaluate the certification criteria and inspection process for EHRs.
Pursuant to the HHS contract, CCHIT takes the AHIC recommendations that
have been accepted by the Secretary into account in its activities.
CCHIT also collaborates with the organizations awarded HHS contracts for
standards harmonization, and collaboratives participating in the NHIN
trial implementations.

CCHIT is supported by five workgroups and several expert panels. The
five workgroups are charged with developing certification criteria and
tests for their particular focus areas, including EHR foundation,
network foundation, inpatient EHRs, ambulatory EHRs, and emergency
department EHRs. The expert panels are tasked with recommending to the
workgroups criteria and test scripts on interoperability, security,
privacy and compliance, cardiovascular, and child health.

**ONC: Federal Interdepartmental Health Information Technology
Collaborative \[Multi-agency\]**

The purpose of the Collaborative is to bring together top leaders in the
federal departments engaged in health IT programs so they may use their
resources in ways that are consistent with the health IT initiatives
being promoted to achieve the President's goal. Federal departments that
are members of the Collaborative include: Department of Agriculture,
Department of Commerce, Department of Health and Human Services, Federal
Communications Commission, Federal Trade Commission, National
Aeronautics and Space Administration, and National Science Foundation.

**ONC: Federal Health Architecture \[Multi-agency\]**

The Federal Health Architecture (FHA) Program supports federal health IT
needs by providing a collaborative forum for creating a federal
framework that is interoperable within the federal government, as well
as between other public and private sector organizations. The FHA is
managed by ONC with input from OMB. Lead partners are HHS, DoD, and VA;
more than 20 federal agencies that have a health care line of business
participate.

**ONC: Federal Interagency Health IT Policy Council \[Multi-agency\]**

The interagency Health IT Policy Council was established to coordinate
federal health IT policy decisions across federal departments and
agencies. The aim is to drive the necessary federal action to realize
the goal of widespread health IT adoption. They also focus on the
breakthrough areas arising out of AHIC recommendations that have been
adopted by the HHS Secretary. The breakthrough areas address consumer
empowerment, EHRs, biosurveillance, and chronic care.

**ONC: Health Information Security and Privacy Collaborative**

The Health Information Security and Privacy Collaborative (HISPC) is a
collaborative of 34 states and territories that sought to review
variations in organization-level business policies and state laws that
affect the exchange of health information. Based on that review, the
HISPC states identified solutions and developed implementation plans to
alleviate challenges created by variations in policies and laws. ONC, in
collaboration with AHRQ, contracted with Research Triangle Institute
International (RTI) to create HISPC.

**ONC: Healthcare Information Technology Standards Panel**

Healthcare Information Technology Standards Panel (HITSP), a
public-private partnership, is sponsored by the American National
Standards Institute and funded by ONC. HITSP is composed of more than
300 health related organizations that work together to identify and
harmonize data and technical standards for health IT In response to a
2005 RFP on evaluation of the standards harmonization process for health
IT, the Standards Harmonization Collaborative, a collaborative of 18
independent standards development organizations (SDOs), recommended the
creation of HITSP. HITSP is composed of technical committees that assist
in identifying and analyzing gaps in harmonized standards.

HITSP harmonizes standards for specific priorities, described in "Use
Cases," identified in AHIC recommendations that the Secretary has
adopted, or for other industry consensus processes. HITSP works with
SDOs to ensure that standards meet existing health needs, ensures
specific guidance exists to unambiguously implement the harmonized
standards, and fosters the availability and use of health IT standards
nationally.

**ONC: Nationwide Health Information Network (NHIN)**

The Nationwide Health Information Network (NHIN) is comprised of a set
of exchange standards and specifications, and data use and reciprocal
support agreements intended to provide a secure, nationwide,
interoperable health information infrastructure that will connect
providers, consumers, and others involved in supporting health and
health care. These exchange standards and agreements will enable health
information to follow the consumer, be available for clinical decision
making, and support appropriate use of health care information beyond
direct patient care. ONC is advancing the NHIN as a "network of
networks," formed when geographically-based, organizationally-based, or
person-controlled HIEs use the standards and agreements to exchange
health information among one another (and in many cases, even
internally), promoting interoperability and connectivity of these
networks and the systems they, in turn, connect.

**ONC: Planning for AHIC 2.0**

Plans are underway, through an HHS cooperative agreement, to establish a
successor to the AHIC that is a public-private partnership based in the
private sector. The planned AHIC successor (to be known as "AHIC 2.0")
would assume new governance and priority setting responsibilities
regarding health IT standards and interoperability while bringing
resources from both the public and private sectors.

> *Progress on Plan Objectives*
>
> During the summer of 2007, ONC produced a White Paper on the formation
> of AHIC 2.0 to serve as an illustrative example of what the new
> organization could look like which included AHIC 2.0 as an independent
> and sustainable entity that would include a variety of stakeholder
> representation, including consumers. In August of 2007, a Notice of
> Funding Availability was released to begin a competition to award a
> cooperative agreement to an organization to design and establish AHIC
> 2.0. The competition concluded in January 2008 with an award to LMI,
> working in collaboration with The Brookings Institution. During Stage
> One the grantee will design and launch AHIC 2.0 and this activity is
> expected to take about four (4) months. The AHIC 2.0 will begin its
> activities in the fall of 2008, and AHIC will meet for the last time
> near the end of CY 2008.

**ONC: Secure Messaging Pilot**

In January 2006, the AHIC advanced a recommendation to the Secretary
that originated from the Chronic Care Workgroup, to establish an
evidence base for informed reimbursement policy with respect to secure
messaging. Upon acceptance by the Secretary, it was determined that this
work would be conducted through ONC. The purpose of this project is to
identify and work with three pilot sites to test the value of secure
messaging between patients and their clinicians. The value of secure
messaging technology will be evaluated both qualitatively and
quantitatively.

**ONC: Standardized Measures for Adoption of EHRs**

Many studies on EHR adoption have had limited findings due to lack of
consistent EHR definition and variability in the extent to which the
technology is actually being used. A standardized approach for physician
adoption was first presented in the October 2006 report from the Robert
Wood Johnson Foundation on the state of adoption among physicians,
titled *Health Information Technology in the United States: The
Information Base for Progress.*  The report also provided a base level
of outpatient adoption based on this methodology of 9.2 percent. ONC is
supporting work to develop standardized methods for measuring adoption.
A consistent and standardized approach to measuring adoption and use of
EHRs are critical to monitoring progress and to assessing the effect of
various initiatives taken to increase the rate of adoption.

**ONC: State Alliance for e-Health**

The State Alliance for e-Health was designed to build state government
consensus across jurisdictions on many issues related to HIE, including
privacy and security. Launched in October 2006 by the National Governors
Association Center for Best Practices, under a contract with ONC, the
State Alliance is composed of state governors, legislators, high-level
officials, and technical experts.

The State Alliance has three taskforces devoted to discrete issues. The
Health Information Protection Taskforce is focused on privacy and
security and development of solutions identified by the HISPC. The
Health Care Practice Taskforce is focused on licensure issues, state
laboratory laws, and liability concerns. The Health Information
Communication and Data Exchange Taskforce is focused on opportunities
for publicly funded programs (e.g., Medicaid) to participate in health
information exchanges.

**ONC: State Level Health Information Exchange Consensus Project**

In March 2006, ONC contracted with the American Health Information
Management Association to gather information from existing state-level
HIE initiatives to determine successful governance and legal, financial,
and operational characteristics, and to develop consensus on guidance
for developing state-level HIE initiatives. Nine states were selected to
participate in the first phase, which included the development of
consensus on best practices for state-level HIEs. The final report
detailing findings from phase was completed in September 2006. The
second phase, which focuses on the roles in ensuring governance and
advancing interoperability of HIEs, will be completed with a final
report in 2008.

**ONC: Terminology Consensus Project**

The multiple and often overlapping meanings health care has attributed
to health IT terms poses a barrier to communication and has long been an
obstacle to progress in IT adoption. By establishing a basic definition
for all to use, the following actions will become achievable:

-   Creating legislation that is understandable, consistent with
    industry efforts and does not work at cross-purposes with other
    policy, lawmaking, or regulation.

-   Explaining IT concepts in language that the American public can
    comprehend and that is relevant to what they consider important to
    their health.

-   Establishing a dialogue between IT vendors and their customers on
    expectations for the features of electronic record products and the
    elements of information sharing.

-   Holding both sides of a contract accountable for performance and
    acceptance of well-understood agreements on general components of an
    IT product or service.

-   Promoting the benefits of health information creation and
    responsible sharing with one clear voice and a minimum of
    conflicting messages.

**ONC: Use Case Development**

Use cases are descriptions of events that detail what a system (or
systems) needs to do to achieve a specific mission or stakeholder goals.
The use cases -- based in part on recommendations from the AHIC that
were accepted by the HHS Secretary -- describe relevant stakeholders,
information flows, issues, and systems needs that apply to the multiple
organizations participating in these specified data exchanges. The use
cases strive to provide enough detail and context for standards
harmonization, architecture specification, certification consideration,
and detailed policy discussions to advance the national health IT
agenda.

> *Progress on Plan Objectives*
>
> In reference to Anti-Fraud Activities, RTI released a report in August
> 2007 that included 14 functional requirements that would serve to
> increase efficiency and improve billing accuracy for clinicians using
> EHRs. Many of the recommendations are designed to improve existing
> standards for electronic health record systems
>
> In July 2006, CCHIT announced its first certified ambulatory EHR
> products, which meet recognized criteria for functionality, security,
> and interoperability. The number has increased to almost 100 certified
> products, covering 75% of the installed market. In November 2007,
> CCHIT announced the certification of the first six inpatient EHR
> products, representing 25% of the market. CCHIT incorporates privacy
> and security provisions into their certification criteria. In 2008,
> CCHIT plans to expand certification to include interoperable health
> information networks that will include privacy and security technical
> criteria.
>
> The Federal Interdepartmental Health IT Collaborative meets on a
> regular basis to discuss, coordinate, and collaborate on existing
> health IT programs.
>
> FHA accomplishments to date include:

-   FHA has created the first investment, planning and health
    information reporting guide, for use by agencies for planning health
    IT implementation and reporting progress.

-   FHA has created the Federal Consortium to connect agencies within
    the federal government and with state, local, and tribal
    governments, as well as the private sector, to enable the secure
    exchange of interoperable health information.

-   The Consolidated Health Informatics (CHI) Initiative put forward and
    received endorsement from the Secretary of HHS along with DoD and VA
    for over 20 standards for health IT which focused on medical
    vocabularies, messaging, EHRs and health care imaging.

-   FHA has defined five federal health service domains: Access to Care,
    Population Health and Consumer Safety, Health Care Administration,
    Health Care Delivery Services, and Health Care Research and
    Practitioner Education.

-   FHA's Food Safety Work Group has defined better business processes
    to protect the nation's food supplies.

-   FHA has coordinated federal input into the health IT standards
    harmonization, interoperability specifications and gap analysis of
    standards for initial HITSP activities and nationwide health
    information network (NHIN) processes.

> The Federal Interagency Health IT Policy Council meets biweekly to
> coordinate Federal health IT activities, disseminate information about
> agency activities related to health IT, and discuss health IT policy
> issues raised by Policy Council members or that are being discussed by
> the American Health Information Community, NCVHS, and others.
>
> In July 2007, the Health Information Security and Privacy
> Collaborative (HISPC) released three reports: (1) the final assessment
> of variations; (2) a summary of the individual states' plans for
> implementing solutions to resolve conflicts or inconsistencies among
> state and federal privacy and security laws; and (3) a nationwide
> summary that presents a comprehensive overview of the project and
> recommendations for future directions. HISPC also produced a tool kit
> to help states conduct similar assessments of variations in state
> privacy laws that affect the exchange of health information and foster
> multi-stakeholder collaborative approaches to identifying and
> implementing appropriate solutions.
>
> The Health Information Technology Standards Panel has completed three
> sets of interoperability specifications that include 30 consensus
> standards and more than 800 pages of specific implementation guidance
> that describes how these 30 standards need to be used. They have
> released initial drafts of four other sets of interoperability
> specifications that will be finalized shortly. In October 2007, HITSP
> released a set of privacy and security standards intended to ensure
> the privacy and security of electronically transferred patient
> information. The standards will serve as an overarching technical
> foundation that will be incorporated into all interoperability
> specifications.
>
> As of November 2007, ONC awarded contracts to nine
> geographically-based health information exchange organizations to
> begin trial implementations of the Nationwide Health Information
> Network. A tenth HIE has been formed across federal health care
> delivery programs (DoD, VA, IHS). The HIEs will participate in the
> NHIN Cooperative, which is a collaborative to test and demonstrate
> core technical services to enable basic exchange of health information
> between the different HIE networks, patients, and other stakeholders.
> In addition, each of the contractors will test two of the seven
> breakthrough use cases, as recommended by the AHIC and accepted by the
> Secretary.
>
> The Secure Messaging Pilot Project was awarded to Abt Associates. Abt
> Associates has subcontracted with three pilot sites to establish
> secure messaging between clinicians and their patients.
>
> In August 2005, ONC contracted with George Washington University and
> Harvard/Massachusetts General Hospital to develop a standardized
> methodology to measure the rate of adoption of EHRs among physicians
> and hospitals. A 2007 outpatient survey was conducted using this
> methodology to determine outpatient rate of adoption. The CDC (through
> its Center for National Health Statistics) will conduct ongoing
> surveys in the future.  A 2008 survey by the American Hospital
> Association will be conducted to measure inpatient adoption.
>
> In August 2007, the State Alliance accepted recommendations from the
> two taskforces devoted to privacy and security issues. The Health
> Information Protection Taskforce recommendations focused on methods to
> facilitate greater state-federal interaction on important health IT
> issues. The Health Care Practice Taskforce recommendations dealt with
> resolving telehealth barriers created by a lack of uniformity in the
> licensure process A critical pathways report will be developed, which
> will include the recommendations from all three taskforces.  This
> report will be published in 2008.
>
> In September 2007, the American Health Information Management
> Association, (AHIMA) through a contract with ONC, released a
> preliminary report detailing state-level HIEs' roles in ensuring
> governance and advancing interoperability. Recommendations from the
> report include that each state should support and participate in a
> public-private entity that would take on a distinct HIE governance
> role, and that each state should designate a formal leader who will
> foster coordination within state government to facilitate HIE
> participation, investments, and strategies across executive agencies.
>
> The contract "Reaching Consensus: Defining Key Health Information
> Technology Terms" was awarded in September 2007 to develop a consensus
> definition for EMR, EHR, PHR, HIE, and RHIO. This report has been
> released.
>
> In December 2005, ONC developed use cases on laboratory results
> reporting, registration and medication history, and visit,
> utilization, and lab result data. In May 2007, HITSP completed
> harmonized interoperability specifications for these data exchange
> scenarios. CCHIT has also incorporated aspects of the use case into
> their certification criteria for ambulatory and inpatient EHRs.
>
> In August 2006, ONC developed use cases on emergency responder EHRs,
> consumer access to clinical information, medications management, and
> quality. HITSP has begun harmonizing relevant standards to the use
> cases and has released draft interoperability specifications for
> comment. The harmonized use cases should be finalized in 2008.
>
> In January 2007, ONC developed use cases in the areas of remote
> monitoring, remote consultation, personalized healthcare, consultation
> and transfers of care, immunizations and response management, and
> public health case reporting. Once ONC has finalized more developed
> versions of the use cases that incorporate stakeholder comments, HITSP
> will begin harmonizing standards and developing interoperability
> specifications that pertain to the use cases.

**[OFFICE OF THE SECRETARY (HHS/OS)]{.underline}**

**HHS/OS: Personalized Healthcare**

The Secretary of HHS launched The Personalized Healthcare Initiative to
improve the safety, quality, and effectiveness of health care for every
patient in the US. The initiative is based on the principle of tailoring
medicine to each person's needs through the use of "genomics," or the
identification of genes. HHS seeks to advance this initiative through
two guiding principles:

-   Provide federal leadership supporting research addressing individual
    aspects of disease and disease prevention with the ultimate goal of
    shaping preventive and diagnostic care to match each person's unique
    genetic characteristics

-   Create a "network of networks" to aggregate anonymous health care
    data to help researchers establish patterns and identify genetic
    "definitions" to existing diseases

HHS has formed four building blocks or goals to guide the implementation
of the Personalized Healthcare Initiative. The first goal seeks to
establish a secured electronic system to exchange, aggregate and analyze
key data from a large number of existing secure health care databases.
Secondly, HHS looks to support the science and health IT base and enable
it to expand, as well as support efficient and effective drug
development partnerships between public and private sector leadership.
Lastly, HHS will help to integrate through various efforts the
Personalized Healthcare Initiative into the mainstream of clinical
practice.

**HHS/OS: Value Driven Health Care**

President Bush's Executive Order: Promoting Quality and Efficient Health
Care in Federal Government Administered or Sponsored Health Care
Programs ("Executive Order 13410"), issued August 22, 2006, called for
increased transparency in health care.

This Executive Order established the four "cornerstones" of Value-driven
Health Care:

-   Interoperable health information technology (health IT)

-   Transparency of price

-   Transparency of quality

-   Use of incentives to promote high-quality and cost-efficient health
    care

The Executive Order directs federal agencies that sponsor or administer
federal health plans (e.g., Medicare, Medicaid, the Federal Employees
Health Benefit Program (FEHBP), and TRICARE) to take steps to implement
these cornerstones to the extent permitted by law. The Executive Order
is available at
<http://www.whitehouse.gov/news/releases/2006/08/20060822-2.html>. 

**Private Sector Initiatives**

Secretary Leavitt announced on November 17, 2006, the corresponding
non-federal initiative of Value-driven Health Care as a critical
component of nationwide health IT interoperability. To achieve this goal
initiatives have been launched in several arenas. 

*Communities*

Communities are encouraged to form collaborations among purchasers,
health plans, providers, and consumers to transform health care at the
local level through quality improvement and public reporting.  Two types
of community collaborations are being recognized by HHS: Community
Leaders and Chartered Value Exchanges. In recognizing collaboratives as
Community Leaders, the Secretary is looking for multi-participant
organizations that are able to foster multi-stakeholder collaboration
within a community including health care providers, health plans,
employers and consumers. Community Leaders should have the support and
participation of leading business, civic and health care organizations
and serve as a convener to advance the four cornerstones of value-driven
health care. Recognized Community Leaders who have more fully developed
their capacity to achieve the four cornerstones are eligible to become
chartered as a Value Exchange. A Chartered Value Exchange (CVE) is a
multi-stakeholder organization that has taken clear action in their
community to convene industry stakeholders and advance the four
cornerstones of Value-driven Health Care. In addition to the imprimatur
that comes with being recognized as a Community Leader, CVEs will be
invited to participate in a nation-wide Learning Network.

*Employers*

Employers provide the majority of health insurance coverage for
Americans.  Employers are encouraged to sign a statement of support and
request information from their health plans, third party administrators,
providers, and others with which they contract about how they are
supporting the four "cornerstones." Employers are also encouraged to use
a request for information/proposal (RFI/RFP) as a way to assess the
extent to which health plans are consistent with the principles of
value-driven health care. A sample RFI is available for employers as a
guide to inform their discussions with plans.

*Insurer Programs*

A number of private insurers, including Blue Cross and Blue Shield
Plans, Aetna, UnitedHealthCare, Humana, and Cigna, have launched
programs to provide members with information about health care quality
and promote measurement of provider performance.  Tools allow consumers
(either patients or employers) to compare physicians and hospitals.

*State and Local Governments*

State and local governments are one of America\'s largest employers and
purchasers of health care and have also joined in the value-driven
health care initiatives. The Secretary works in partnership with states
and local governments to implement the principles of value-driven health
care.  HHS works with the National Governors Association (NGA) in
educating governors and their staff about the importance of health care
transparency. Through a series of issue briefs, conference calls, Web
casts, and roundtables, NGA has engaged policymakers in dialogue about
issues relating to advancing value-driven health care.

> *Progress on Plan Objectives*
>
> In reference to Personalized Healthcare, HHS issued a request for
> information (RFI) to solicit input from the public and private sectors
> on plans for developing and using resources involving health IT and
> genetic and molecular medicine, with specific reference to
> incorporating these capacities in evidence-based clinical practice,
> health outcomes evaluations, and research.
>
> In reference to Value Driven Health Care, over 800 employers have
> signed on to support the four cornerstones and will help advance both
> interoperable health IT and population health information uses for
> quality and cost reporting. Similarly, 11 states and 12 cities,
> counties, or local government agencies have either signed statements
> of support or taken other significant steps in support of Value-driven
> health care.

**[SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
(SAMHSA)]{.underline}**

**SAMHSA: Health IT Initiatives**

SAMHSA aims to ensure that an electronic health record system includes
features specifically designed for behavioral health consumers,
caregivers, and providers. SAMHSA\'s goal is to empower individuals
receiving and providing behavioral health care to take full advantage of
the opportunities created by the rapidly approaching era of electronic
health information and also to receive the protection they deserve for
their highly sensitive health information. Projects to support this goal
include the development of a behavioral health functional model for
certification of EHRs, technical assistance for development and reuse of
an open source EHR by state and county behavioral health agencies, an
HL7 messaging standard for consumers to transmit privacy consents that
control who can access their personal data, a structured vocabulary for
privacy consents, a white paper on e-consent mechanisms in other
countries, privacy FAQs on the Federal Confidentiality of Alcohol and
Drug Abuse Patient Records regulation in the electronic environment, as
well as the development of a secure system for sharing opioid addiction
treatment protocols in emergency situations when treatment records are
not accessible.

[]{.mark}

[]{.mark}

> *Progress on Plan Objectives*
>
> The HL7's Electronic Health Record System Functional Model was adopted
> as an ANSI standard in February 2007. SAMHSA is currently working on
> the Behavioral Health Conformance Profile for the functional model.
> Three HL7 version 3 models pertaining to consumer control of their
> health information have almost reached normative status and are
> planned for use in an upcoming interoperability demonstration led by
> VA security experts. SAMHSA has also produced a white paper, "The
> Implementation of E-consent Mechanisms in Three Countries: Canada,
> England, and the Netherlands (The ability to mask or limit access to
> health data)", which was disseminated in February 2007.

**[DEPARTMENT OF COMMERCE]{.underline}**

**[NATIONAL INSTITUTE OF STANDARDS & TECHNOLOGY]{.underline}**

**NIST: Conformance Testing Infrastructure**

The National Institute of Standards and Technology (NIST) develops
conformance test suites, tools, methods, and prototypes to achieve
high-quality, interoperable implementations that conform to standards
and meet users\' needs. New test generation techniques are also
developed. NIST partners with ONC and the health IT industry to develop
standards, tests, tools, and prototypes to advance the use of
information technologies in health care systems and achieve an
interconnected electronic health information infrastructure.

**NIST: Security Technology**

NIST engages the health IT community in technical security
implementation assistance through publication of resource guidance on
federal implementation of the HIPAA security rule and through outreach
and awareness activities such as the CMS/NIST joint workshop on HIPAA
Security Rule implementation which included presentations from ONC,
HITSP, and CCHIT. For federal agencies, NIST also has a series of
Special Publications and Federal Information Processing Standards, which
detail information security requirements and guide federal
implementation of the Federal Information Security Management Act and
other federal information security and privacy policies and laws.

**NIST: Conformance and Certification Expertise**

NIST consults with emerging health IT certification bodies to help move
them toward the implementation and accreditation to ISO standards for
certification bodies. Also, NIST provides guidance on conformance
topics, including how to specify conformance and communicate
requirements for claiming conformance in specifications, as well as how
to develop conformance test suites and tools.

> *Progress on Plan Objectives*
>
> NIST has continued to provide technical expertise for standards
> development. In the area of conformance and interoperability testing,
> NIST developed: a testing toolkit to validate HL7 messages for use
> with DICOM (radiology imaging) testing and Certification Commission
> for Healthcare Information Technology (CCHIT) interoperability
> testing; and, a tool to validate Continuity of Care Document messages
> for conformance to HITSP specifications. To assist with standards
> harmonization, NIST developed a health IT web portal providing
> interactive, electronic access to HHS Secretary-recognized and
> accepted use cases, HITSP specifications, and related test materials.
> NIST served as a technical advisor to the CCHIT for other matters such
> as testing methods, security, selection of jurors, and statistical
> tests of juror bias. In the area of security technology, NIST provided
> subject matter expertise to the CCHIT Security Workgroup and jointly
> sponsored in January 2008 with CMS a workshop on HIPAA Security Rule
> implementation and is currently updating guidance.

**[DEPARTMENT OF DEFENSE]{.underline}**

**DoD: AHLTA**

AHLTA is a secure, standards-based, and patient centric EHR for use in
garrison-based medical facilities and forward-deployed medical units.
AHLTA provides military physicians with decision support and builds a
single encounter document out of a team effort, linking diagnoses,
procedures, and orders into one record. It creates a life-long,
computer-based patient record for each and every military health
beneficiary, regardless of their location, and provides seamless
visibility of health information across the entire continuum of medical
care. This gives military providers unprecedented access to critical
health information whenever and wherever care is provided to our service
members and beneficiaries.

**DoD: Memorandum of Agreement with the State of Florida**

On April 4, 2007, DoD signed a Memorandum of Agreement with the State of
Florida establishing an unprecedented partnership to pursue the cross
network exchange of health care information that will enhance the
quality and efficiency of medical care for our mutual beneficiaries.
This pilot collaboration between DoD and Florida is a model initiative
to create a mechanism to share and exchange personal health information
and data.

> *Progress on Plan Objectives*
>
> DoD AHLTA serves as a test bed for EHR standards and improved clinical
> support tools. The Florida initiative will help pilot interoperability
> and population health information use activities.

**[DEPARTMENT OF VETERAN AFFAIRS]{.underline}**

**VA: Electronic Health Records (VistA, CPRS**)

VistA supports quality health care with an integrated health information
and management system that is available in all VA health care
facilities. The VistA framework consists of more than 100 programs that
support the day-to-day clinical, financial, and administrative functions
of the Veterans Health Administration (VHA). VHA developed the
Computerized Patient Record System (CPRS) to provide a user interface
for the information captured in VistA. With CPRS, VHA health care
professionals can access patient information at the point of care across
multiple sites and clinical disciplines.

**VA: Personal Health Record (My Health*[e]{.underline}*Vet)**

My Health***[e]{.underline}***Vet is a nationwide initiative intended to
improve the overall health of veterans. The My
Health***[e]{.underline}***Vet portal provides a secure, online
environment where veterans can view and manage their personal health
record, access clinically relevant and objective health information
perform health assessments and use electronic services such as
prescription refill. My Health***[e]{.underline}***Vet gives veterans an
active role in their health care planning.

**VA: Telehealth**

The VA has several Telehealth initiatives, both internal to the
Department and in conjunction with DoD. These initiatives draw on
general telehealth, health informatics, and disease management,
and include:

-   National care coordination home telehealth program (CCHT). Patients
    are connected to Care Coordinators, who take assessments and receive
    electronically transmitted health readings from instruments placed
    in the veterans' homes. Early detection of possible health crises
    and helping veterans negotiate their way across the continuum of
    care are two of the major benefits.

-   Specific telehealth programs focus on: retinal imaging for diabetes,
    mental health, rehabilitation, dermatology, and surgery.

> *Progress on Plan Objectives*
>
> In reference to Health IT adoption, VA has fully implemented its
> Computerized Patient Record System (CPRS) as a longitudinal record
> available wherever the Veteran seeks care from the Veterans Health
> Administration. CPRS provides VHA with a great deal of clinical health
> IT functionality, including clinical decision support and the capture
> of data in an electronic format, as well as an effective and efficient
> method for population health reporting.
>
> My Health***[e]{.underline}***Vet was a top-five winner of the 2007
> Excellence.Gov awards for IT innovation and collaboration. My
> Health***[e]{.underline}***Vet is an important test bed for assessing
> data access and translation for PHRs. The national system has over
> 500,000 registrants, and veterans have filled over 4.5 million
> prescriptions using the system.  Veterans routinely record their
> health readings (e.g., blood glucose, blood pressure, pulse oximetry,
> etc.), health histories (self, family, military), and other pertinent
> health information, such as medications and medical visits.  In
> addition, they routinely use activity and food logs to record their
> intake and physical activities, and are printing health summaries to
> take to their appointments with health care providers. 

**[FEDERAL COMMUNICATIONS COMMISSION]{.underline}**

**FCC: Rural Health Care Pilot Program (RHCPP)**

In September 2006, the FCC adopted an order, pursuant to section
254(h)(2)(A) of the Telecommunications Act of 1996, to establish the
RHCPP to examine how the rural health care funding mechanism could be
used to enhance public and nonprofit health care providers' access to
advanced telecommunications and information services. Specifically, the
RHCPP provides funding to support up to 85 percent of the costs
associated with: (1) the construction of a state or regional broadband
network and the advanced telecommunications and information services
provided over that network; (2) connecting to Internet2[^6] or National
LambdaRail (NLR[^7]); and (3) connecting to the public Internet. These
networks will be designed to bring the benefits of innovative telehealth
and, in particular, telemedicine services to those areas of the country
where the need for those benefits is most acute. Where feasible,
participants are required to implement health IT standards identified by
HHS. The health care facilities participating in RHCPP include
hospitals, clinics, universities and research centers, behavioral health
sites, correctional facility clinics, and community health centers.

> *Progress on Plan Objectives*
>
> On November 19, 2007, the FCC awarded more than \$417 million for the
> construction of 69 statewide or regional broadband telehealth networks
> in 42 states and three U.S. territories. The RHCPP will support the
> connection of more than 6,000 public and non-profit health care
> providers nationwide to broadband telehealth networks.

**[Social Security Administration]{.underline}**

**SSA: Medical Evidence Request and Data Use Prototype**

SSA requests approximately 15-20 million medical records each year from
providers all over the country on behalf of, and with the authorization
of, millions of individuals applying for disability benefits. In some
cases, medical sources have difficulty providing medical records,
oftentimes due to the labor costs associated with the pulling,
extracting, printing and handling of the records. These delays and
response failures can have a significant affect on the timeliness of
claims processing for disability benefits. Disability benefits provide a
monthly income and may also lead to certain types of health insurance
coverage through Medicare and Medicaid. Not only does the applicant
benefit through timely decisions, but the provider benefits through such
things as the receipt of payment for records. Developing electronic
methods of communication which relieve the provider of the burden
currently associated with delivering records, will provide benefit for
all parties. Work is underway to establish a standards-based request and
receipt process which will streamline the disability claims development
process. Included in this effort is the development of computer-based
intelligent analysis of the data being returned by the provider which
will identify potential areas of the disability listings which the
examiner may focus on to expedite review and processing. The prototype
will be operational by October, 2008.

**SSA: NHIN "Release of Information to a Trusted Entity" Use Case
Funding and Participation**

The Medical Evidence Prototype referenced above will be furthered
through the NHIN efforts. SSA has funded the use case to work toward
formalizing the standards effort begun in the Medical Evidence
Prototype. Standards for the handling of the patient's authorization for
the release of medical records and for the content of the medical record
delivered will be vetted with the NHIN participants and submitted to the
HITSP for consideration. In 2008, the NHIN Trial Implementations will
employ these standards to demonstrate a nationally scalable exchange
using test data. In 2009, SSA plans to put this process into production
with interested NHIN participants.

**SSA: Personal Health Record Prototype**

Individuals filing for Social Security disability benefits start the
process by providing a comprehensive list of conditions, medications,
treating sources, and treatments. This can represent a significant
effort on the part of the individual, and frequently critical
information affecting the claims process is overlooked. The type of
information individuals need to provide to SSA is represented in the
typical PHR, whether populated through claims data, or by the patient or
providers. SSA will develop a prototype in 2009 to study the ways
through which a standards-based communication could gather information
already existing in the PHR, with the patient's authorization, and more
simply and effectively begin the disability claims process.

**[MULTI-AGENCY COLLABORATIVE EFFORTS]{.underline}**

**AHRQ, FDA, NLM, NCI, and VA Data Standards Program (also known as
Federal Medication Terminologies)**

Collaboration among AHRQ, FDA, NLM, NCI, and VA resulted in
standardizing the flow of drug information from drug manufacturers to
FDA (for labeling information approval) to NLM (for assignment of RxNorm
codes and display on NLM's DailyMed web site)---with standardized
terminology and use of HL7's SPL standard. Additionally, this program
supported the development of the Unique Ingredient Identifier (UNII) by
FDA and the development of RxNorm by NLM. The goal is to improve drug
safety and quality of care by making federally approved drug information
available in a uniform, standardized, computer-retrievable manner in
real time.

**DoD & VA: Exchange of Information**

The collaborative federal partnership between Department of Defense
(DoD) and Department of Veterans Affairs (VA) has resulted in increased
integration of health care services to military service members and
veterans. There are multiple initiatives that support timely transfer of
data, real-time data sharing, shared data resources and sharing of
critical test data to support more efficient use of resources and
appropriate care coordination. The initiatives are called:

-   Federal Health Information Exchange (FHIE)

-   Bidirectional Health Information Exchange (BHIE)

-   Clinical Data Repository/Health Data Repository (CHDR)

-   Transfer of Radiology Images and Scanned Medical Records from DoD to
    VA Polytrauma Centers

-   Laboratory Data Sharing Initiative (LDSI)

**DoD & VA: Joint Inpatient Electronic Health Record Analysis Project**

The Joint project will have two phases. The first phase will document
and assess DoD and VA inpatient clinical processes, workflows, and
requirements. The second phase will be an analysis of alternatives, a
business case, and a recommendation for achieving a joint inpatient
electronic health record solution with associated cost and schedule.

**OIG & CMS: Hospital Donation of Health IT**

The Anti-Kickback Statute, a criminal statute, enacted over 30 years ago
prohibits any knowing or willful solicitation or acceptance of
remuneration to induce referrals for health care services that are
reimbursable by the Federal Government. The Department of Justice is
responsible for criminal enforcement of the statute and the HHS Office
of the Inspector General (OIG) is authorized to impose administrative
sanctions such as program exclusion and civil monetary penalties when
the statute has been violated. The statute sets forth certain voluntary
"safe harbors" which, if fully complied with, insulate an arrangement
from enforcement. The OIG is authorized to promulgate additional "safe
harbors" by regulation.

The physician self-referral prohibition, commonly referred to as the
"Stark" law, prohibits a physician from referring Medicare patients for
inpatient and outpatient hospital services and certain other "designated
health services" an entity with which the physician (or an immediate
family member of the physician) has a financial relationship unless an
exception applies. The Stark law prohibits the entity from submitting
claims to Medicare for designated health services that are furnished as
a result of a prohibited referral. The statute enumerates various
exceptions and grants the Secretary the authority to establish
additional exceptions by regulation for financial relationships that do
not pose a risk of program or patient abuse. Violations of the statute
are punishable by denial or payment for all designated health services
claims, refund of amounts collected for designated health services
claims, and civil money penalties (imposed by OIG) for knowing
violations of the prohibition.

Because financial arrangements designed to assist physicians with the
acquisition of health information technology implicates these statutes,
both laws were believed to inhibit the use of health information
technology. In recognition of this impact, the Medicare Modernization
Act of 2003 required OIG to promulgate an anti-kickback safe harbor and
CMS to promulgate a Stark exception in order to foster the donation and
use of e-prescribing technology tools.

> *Progress on Plan Objectives*
>
> *(Referring to all multi-agency collaborative efforts described
> above)*
>
> Some of the significant accomplishments in the Data Standards Program
> in 2007 include: increasing the pipeline of valid drug labeling
> information to NLM's DailyMed website; a significant reduction in
> distinct NDC drug package codes inaccurately linked to RxNorm; and an
> increase in the number of unique drug ingredients in the UNII code
> system
>
> DoD and VA have been exchanging health information since 2001.
> Progress includes:
>
> FHIE: As of September 2007, DoD has transferred health information for
> over 4.0 million patients to the FHIE data repository. As of September
> 2007, over 2.5 million patient messages (i.e. laboratory results,
> radiology reports, pharmacy data, and consults) have been transmitted
> on VA patients treated in DoD facilities.
>
> BHIE: In July 2007, DoD made data viewable to VA from AHLTA, DoD's
> electronic health record. Data are viewable to DoD from all VA
> facilities.
>
> CHDR: In September 2006, the Departments established interoperability.
> The exchange of computable outpatient pharmacy and medication allergy
> data enables drug-drug interaction checking and drug-allergy checking
> using data from both departments.
>
> LDSI: LDSI for laboratory chemistry tests is available for use
> throughout DoD, and is actively being used daily between DoD and VA at
> several sites where one Department uses the other as a reference
> laboratory. LDSI is now operational at more than 9 joint VA/DoD sites.
>
> DoD & VA are working on assessing the requirements and best approach
> for a joint inpatient electronic health record.
>
> On August 8, 2006, OIG and CMS published final regulations under the
> Anti-Kickback Statute and Stark Law concerning the donation of eRx and
> EHR technologies. In addition to promulgating the MMA-mandated
> anti-kickback safe harbor and Stark exception for eRX technology, OIG
> and CMS promulgated a safe harbor and an exception, respectively, for
> certain arrangements involving the donation of electronic health
> records (EHR) technology. The EHR safe harbor and exception protect
> certain arrangements in which hospitals, group practices, prescription
> drug plan sponsors, and Medicare Advantage Plans provide interoperable
> EHR software and information technology as well as training services
> to physicians (and under the Anti-Kickback Statute, other individuals
> and entities, such as pharmacists). The EHR safe harbor and exception
> sunset December 31, 2013; the eRx provisions do not. In response to a
> November 2006 request for guidance from a provider association, the
> IRS issued a memorandum clarifying that 501(c)(3) hospitals may donate
> health IT software to physicians under specified conditions without
> risking their tax-exempt status.

**[Other Public-Private Sector Initiatives]{.underline}**

**National Quality Forum National Priorities and Goal Setting Project**

The National Quality Forum (NQF) is conducting a project to develop a
measurement framework to assess value over episodes of care for chronic
conditions. The goal of this project is to move towards a better
alignment of measurement development and reporting activities within
national priorities and goals. The project steering committee has
identified national priorities and corresponding three to five year
goals. Two priority conditions, acute myocardial infarction and lower
back pain, will serve as operational examples. The scope of the project
includes:

-   development of a measurement framework for chronic care episodes;

-   identification of a starting subset of priority conditions;

-   assessment of efficiency in the priority areas, including quality
    measurement and data collection;

-   establishment of national performance goals; and

-   development of a research agenda for continued measurement and
    monitoring focused on value across episodes of care.

The project to assess quality over episodes of care relies on the
ability to collect longitudinal data in an efficient fashion. NQF is
working to assess the availability of the needed data and develop
methods to address gaps and areas of need. These data needs will help to
inform the research agenda for an evolving quality measurement and
monitoring system.

> *Progress on Plan Objectives*
>
> In 2007, AHRQ, CMS, and NQF released a draft report outlining a
> measurement framework for evaluating efficiency in episodes of care.
> The group accepted public comments until December 2007. Subsequently
> they will use the comments to finalize the report. The framework is
> intended to provide guidance to help key stakeholders move towards a
> higher performing health care system that is patient-focused and
> focused on quality. It will also serve to help define needed quality
> information that can be supported through health IT.

**FEDERAL ADVISORY COMMITTEES**

**National Committee on Vital and Health Statistics**

The National Committee on Vital and Health Statistics (NCVHS),
established by Congress, serves as a Federal Advisory Committee Act
(FACA) committee to provide recommendations to the Secretary of the
Department of Health and Human Services on health data, statistics, and
national health information policy and also has statutory
responsibilities under HIPAA. NCVHS's 18 person membership possesses
expertise in a wide array of health IT related fields including
electronic data exchange, privacy and security, public health and health
services research, health care delivery, health care financing,
computerized health information systems, and health data standards.
NCVHS is supported by several standing and ad hoc subcommittees and
working groups that address relevant health IT issues:

-   Subcommittee on Privacy and Confidentiality

-   Subcommittee on Standards and Security

-   Executive Subcommittee's Work Group on National Health Information
    Infrastructure

-   Subcommittee on Populations' Work Group on Quality

-   Work Group on Uses of Health Data (formerly the Work Group on
    Secondary Uses of Data)

> *Progress on Plan Objectives*
>
> In October 2007, NCVHS released draft recommendations on "Enhanced
> Protections for Uses of Health Data: A Stewardship Framework for
> 'Secondary Uses' of Electronically Collected and Transmitted Health
> Data. In June 2007, NCVHS sent a letter to the Secretary of HHS
> recommending that HHS and Congress move expeditiously to establish
> laws to ensure that all entities that create, compile, store,
> transmit, or use personally identifiable health information are
> covered by a federal privacy law. In November 2006, NCVHS released a
> draft paper that described the critical privacy and security elements
> for connecting to the NHIN. In June 2006, NCVHS released a report,
> \"Privacy and Confidentiality in the Nationwide Health Information
> Network."

**American Health Information Community**

The American Health Information Community (AHIC), a Federal advisory
committee, was created by the Secretary of Health and Human Services
(HHS) in June 2005. The AHIC provides recommendations which seek to
advance the President's goal calling for most Americans to have access
to secure, interoperable electronic health records (EHRs) by 2014. To
achieve this goal, the AHIC provides recommendations to the HHS
Secretary on how to accelerate the development and adoption of health
information technology (health IT) and to ensure the privacy and
security of electronic health records. The AHIC is composed of no more
than 18 public and private health care stakeholders representing
cross-cutting health interests, including hospitals, health care
providers, health plans, employers, consumers, and federal and state
agencies. The group is chaired by the Secretary of HHS.

The AHIC was originally chartered for two years, with the option to
renew for the duration of no more than five years. The AHIC is supported
by seven workgroups that address specific health information topics and
provide recommendations to the AHIC on advancing progress in specific
areas. Each workgroup has a short- and long-term charge, and has made
progress in the form of recommendations related to those charges.
Detailed information on the workgroups, their charges, and many of the
recommendations they have made to the AHIC are available at
<http://www.hhs.gov/healthit/ahic/>.

> *Progress on Plan Objectives*
>
> The AHIC serves as an example of a federal advisory committee that has
> successfully created a set of consensus recommendations for the HHS
> Secretary from varied and often disparate stakeholders. It has
> provided critical advice to the Secretary of HHS, which has helped the
> Department to set the agenda for the advancement of health IT
> interoperability and adoption. AHIC has identified priority focus
> areas and created workgroups to explore them in greater detail.
> Subsequently, the AHIC reviewed, vetted, and fully considered the
> workgroup draft recommendations before advancing its own
> recommendations to the HHS Secretary. Finally, the AHIC provided
> feedback to the Secretary regarding the next steps for the AHIC as a
> whole, including the development of a plan for AHIC 2.0.

Each workgroup is described in greater detail below. The dates indicated
reflect the year the workgroup was formed.

-   **AHIC Chronic Care Workgroup (2005):** The Chronic Care Workgroup
    focuses on identifying and recommending ways to the AHIC to
    facilitate the deployment of widely available, secure technology
    solutions, such as secure messaging, for remote monitoring and
    assessment of chronically ill patients, and for communication
    between clinicians about patients. The workgroup is comprised of 20
    members who represent an array of health care sectors such as health
    plans, federal agencies, employers, academic research centers, and
    disease advocacy groups.

> *Progress on Plan Objectives*
>
> In May 2006, the AHIC advanced to the Secretary recommendations
> intended to foster the widespread use of secure messaging as a means
> of communication between patients and providers. In June 2007, the
> AHIC advanced additional recommendations related to enabling the
> deployment of widely available, secure technology solutions for remote
> monitoring and assessment of patients and for communication between
> clinicians about patients. As a result of the Secretary's adoption of
> these recommendations:

-   Interoperability standards are being developed for remote monitoring
    devices; and

-   Options for reimbursing care outside the boundaries of the health
    care setting are being explored.

-   Federal Communications Commission (FCC) is supporting wide
    availability of broadband so that both providers and patients can
    access interoperable health care information and use advanced
    telemedicine applications;

-   A pilot study is underway to demonstrate the value of reimbursement
    for secure messaging;

-   Medical licensure across state lines is being addressed by the State
    Alliance for e-Health;

```{=html}
<!-- -->
```
-   **AHIC Confidentiality, Privacy, and Security Workgroup (2006):**
    The Confidentiality, Privacy, and Security (CPS) Workgroup was
    established to advance draft recommendations to the AHIC after
    exploring in greater depth the cross-cutting nature of
    confidentially, privacy, and security issues related to exchange of
    electronic health information. The CPS Workgroup's members consist
    of privacy, security, clinical, and technology experts, and also
    members from other AHIC workgroups.

> *Progress on Plan Objectives*
>
> In January 2007 and March 2007, the AHIC advanced recommendations to
> the HHS Secretary on patient identity proofing and protections needed
> for entities that support the exchange of health information but may
> not be covered under HIPAA. The objective of the latter
> recommendations was to ensure that all entities engaged in the
> exchange of electronic health information meet common baseline privacy
> and security standards that are at least equivalent to HIPAA
> requirements for covered entities.

-   **AHIC Consumer Empowerment Workgroup (2005):** The Consumer
    Empowerment Workgroup was created to advance draft recommendations
    to the AHIC as it examines the challenges to increasing PHR
    utilization by consumers and propose strategies for addressing those
    challenges. The workgroup is composed of 28 members who exhibit a
    diverse set of professional expertise, especially in the areas of
    privacy and security, insurance plans, public sector leadership,
    mental health, standards and development, and consumer advocacy.

> *Progress on Plan Objectives*
>
> The AHIC has advanced 15 recommendations to the HHS Secretary,
> including:

-   Development of a PHR certification process for interoperability,
    portability, privacy, and security;

-   Privacy and security processes and protections for patient oriented
    products;

-   Studies to assess consumer and patient needs with respect to PHRs
    for identifying incentives for adoption; and

-   Education and outreach to increase consumer awareness of PHRs.

```{=html}
<!-- -->
```
-   **AHIC Electronic Health Records Workgroup (2005):** The Electronic
    Health Records (EHR) Workgroup has advanced draft recommendations to
    the AHIC as it explores and analyzes the barriers to widespread EHR
    adoption. The workgroup is composed of 20 members who represent a
    variety of sectors such as health IT vendors, hospitals, federal
    agencies, and private sector health informatics management
    associations.

> *Progress on Plan Objectives*
>
> Over the course of the past 18 months, the EHR Workgroup of the AHIC
> has heard extensive public testimony on the barriers to and enablers
> of EHR adoption in the delivery system. Recommendations the AHIC has
> advanced to the HHS Secretary, and the Secretary has adopted, include:

-   CLIA guidance to allow the flow of historical laboratory results to
    clinicians other than the ordering physician;

-   Interoperability standards for key laboratory results;

-   Pay for performance programs that include structure and process
    measures, as well as outcome measures;

-   On line educational programs to guide adoption and implementation;

-   Privacy and security actions with respect to patient identity
    proofing, authentication, and authorization; and

-   Opportunities to support mandated use of e-prescribing.

-   **AHIC Personalized Healthcare Workgroup (2006):** The Personalized
    Healthcare Workgroup advances draft recommendations to the AHIC
    regarding its four main priority areas: genetic/genomic tests;
    family health history; confidentiality, privacy, and security; and
    clinical decision support. The workgroup is composed of 24 members
    and 17 senior advisors who represent a variety of health care
    sectors such as health care providers, health plans, pharmaceutical
    and diagnostics industry groups, academic research institutions,
    patient advocates, and federal agencies.

> *Progress on Plan Objectives*
>
> In July 2007, the AHIC advanced to the Secretary of HHS
> recommendations intended to guide the process for developing
> consensus-based standards to facilitate the incorporation of
> interoperable, genetic/genomic information and analytical tools into
> EHRs. The recommendations supported the continued implementation of
> the Personalized Healthcare Use Case and called for the creation of a
> multi-stakeholder workgroup comprising of private sector, federal
> health care providers and federal public health service agencies to
> determine the types of information that should be generated when
> performing genetic/genomic tests and to identify standard metrics,
> terminology, language and processes.

-   **AHIC Population Health and Clinical Care Connections Workgroup
    (2005):** The Population Health and Clinical Care Connections
    Workgroup initially began as the Biosurveillance Workgroup. Its
    focus was to advance draft recommendations to the AHIC regarding a
    minimum data set that would aid in the transmission of essential
    ambulatory care and emergency department visit, utilization, and lab
    result data to authorized public health agencies within 24 hours of
    an emergency. The workgroup was then restructured to keep making
    progress through draft recommendations to the AHIC to facilitate the
    flow of reliable health information among population health and
    clinical care systems necessary to protect and improve the public's
    health. The workgroup is composed of 24 members and 4 ex-officio
    members, who represent a variety of health care sectors such as
    hospital associations, health care providers, state and local public
    health agencies, and federal agencies.

> *Progress on Plan Objectives*
>
> In October 2006, the AHIC recommended a minimum data set for
> biosurveillance and public health reporting, which had originated from
> its Biosurveillance Workgroup.
>
> In March 2007, the AHIC advanced to the HHS Secretary the
> recommendations crafted by the Population Health and Clinical
> Connections Workgroup in the areas of the process and business case
> for data/information exchange between public health and clinical care
> entities, case reporting and collaboration to develop a list of
> "nationally notifiable" conditions that would be reported to all
> levels of public health agencies, and proposed initial steps toward
> standardizing alerting and the exchange of contact information across
> public health and clinical care.

-   **AHIC Quality Workgroup (2006):** The Quality Workgroup
    concentrates on drafting recommendations to the AHIC regarding how
    health IT can be used to support quality measurement and
    improvement. The workgroup is composed of 20 members who represent a
    variety of health care sectors such as hospitals, health plans,
    quality measure developers, employers, and federal agencies.

> *Progress on Plan Objectives*
>
> The AHIC advanced a recommendation to the HHS Secretary to enhance
> quality measurement development with improved coordination of
> reporting efforts.

**Appendix D: Planned ONC Fiscal Year 2008 and 2009 Spending Aligned to
the Strategic Plan Goals and Objectives**

(Descriptions of the initiatives listed are found in Appendix C)

+----------------------------------------------+---+---+---+---+---+---+---+---+
|                                              | * |   |   |   | * |   |   |   |
|                                              | * |   |   |   | * |   |   |   |
|                                              | G |   |   |   | G |   |   |   |
|                                              | o |   |   |   | o |   |   |   |
|                                              | a |   |   |   | a |   |   |   |
|                                              | l |   |   |   | l |   |   |   |
|                                              | 1 |   |   |   | 2 |   |   |   |
|                                              | * |   |   |   | * |   |   |   |
|                                              | * |   |   |   | * |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
|                                              | * | * | * | * | * | * | * | * |
|                                              | * | * | * | * | * | * | * | * |
|                                              | O | O | O | O | O | O | O | O |
|                                              | b | b | b | b | b | b | b | b |
|                                              | j | j | j | j | j | j | j | j |
|                                              | 1 | * | * | * | * | 2 | 2 | 2 |
|                                              | . | * | * | * | * | . | . | . |
|                                              | 1 |   |   |   |   | 2 | 3 | 4 |
|                                              | * | * | * | * | * | * | * | * |
|                                              | * | * | * | * | * | * | * | * |
|                                              |   | 1 | 1 | 1 | 2 |   |   |   |
|                                              |   | . | . | . | . |   |   |   |
|                                              |   | 2 | 3 | 4 | 1 |   |   |   |
|                                              |   | * | * | * | * |   |   |   |
|                                              |   | * | * | * | * |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
| **ONC Program Funding**                      | > | > | > | > | > | > | > | > |
|                                              |   |   |   |   |   |   |   |   |
|                                              | * | * | * | * | * | * | * | * |
|                                              | * | * | * | * | * | * | * | * |
|                                              | P | I | A | C | P | I | A | C |
|                                              | r | n | d | o | r | n | d | o |
|                                              | i | t | o | l | i | t | o | l |
|                                              | v | e | p | l | v | e | p | l |
|                                              | a | r | t | a | a | r | t | a |
|                                              | c | o | i | b | c | o | i | b |
|                                              | y | p | o | o | y | p | o | o |
|                                              | > | e | n | r | > | e | n | r |
|                                              |   | r | * | a |   | r | * | a |
|                                              | a | a | * | t | a | a | * | t |
|                                              | n | b |   | i | n | b |   | i |
|                                              | d | i |   | v | d | i |   | v |
|                                              | > | l |   | e | > | l |   | e |
|                                              |   | i |   | > |   | i |   | > |
|                                              | S | t |   |   | S | t |   |   |
|                                              | e | y |   | G | e | y |   | G |
|                                              | c | * |   | o | c | * |   | o |
|                                              | u | * |   | v | u | * |   | v |
|                                              | r |   |   | e | r |   |   | e |
|                                              | i |   |   | r | i |   |   | r |
|                                              | t |   |   | n | t |   |   | n |
|                                              | y |   |   | a | y |   |   | a |
|                                              | * |   |   | n | * |   |   | n |
|                                              | * |   |   | c | * |   |   | c |
|                                              |   |   |   | e |   |   |   | e |
|                                              |   |   |   | * |   |   |   | * |
|                                              |   |   |   | * |   |   |   | * |
+----------------------------------------------+---+---+---+---+---+---+---+---+
| **Department of Health and Human Services -  |   |   |   |   |   |   |   |   |
| ONC**                                        |   |   |   |   |   |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
| > **STANDARDS\                               | * | * | * | * | * | * | * | * |
| > **National Institute of Standards and      | * | * | * | * | * | * | * | * |
| > Technology (NIST) --                       | √ | √ | √ | √ | √ | √ | √ | √ |
| >                                            | * | * | * | * | * | * | * | * |
| > Standards Harmonization (HITSP)            | * | * | * | * | * | * | * | * |
| >                                            |   |   |   |   |   |   |   |   |
| > Technology Certification (CCHIT)           |   |   |   |   |   |   |   |   |
| >                                            |   |   |   |   |   |   |   |   |
| > Federal Data Standards Initiative          |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| AHIC Operations                              |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| AHIC Successor                               |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| > State Level HIE Consensus Project          |   |   |   |   |   |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
|                                              |   |   |   |   |   |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
| **PRIVACY AND SECURITY**                     | * |   |   | * | * |   |   |   |
|                                              | * |   |   | * | * |   |   |   |
| Health Information Security and Privacy      | √ |   |   | √ | √ |   |   |   |
| Collaborative                                | * |   |   | * | * |   |   |   |
|                                              | * |   |   | * | * |   |   |   |
| State Alliance for e-Health                  |   |   |   |   |   |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+

+----------------------------------------------+---+---+---+---+---+---+---+---+
|                                              | * |   |   |   | * |   |   |   |
|                                              | * |   |   |   | * |   |   |   |
|                                              | G |   |   |   | G |   |   |   |
|                                              | o |   |   |   | o |   |   |   |
|                                              | a |   |   |   | a |   |   |   |
|                                              | l |   |   |   | l |   |   |   |
|                                              | 1 |   |   |   | 2 |   |   |   |
|                                              | * |   |   |   | * |   |   |   |
|                                              | * |   |   |   | * |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
|                                              | * | * | * | * | * | * | * | * |
|                                              | * | * | * | * | * | * | * | * |
|                                              | O | O | O | O | O | O | O | O |
|                                              | b | b | b | b | b | b | b | b |
|                                              | j | j | j | j | j | j | j | j |
|                                              | 1 | * | * | * | * | 2 | 2 | 2 |
|                                              | . | * | * | * | * | . | . | . |
|                                              | 1 |   |   |   |   | 2 | 3 | 4 |
|                                              | * | * | * | * | * | * | * | * |
|                                              | * | * | * | * | * | * | * | * |
|                                              |   | 1 | 1 | 1 | 2 |   |   |   |
|                                              |   | . | . | . | . |   |   |   |
|                                              |   | 2 | 3 | 4 | 1 |   |   |   |
|                                              |   | * | * | * | * |   |   |   |
|                                              |   | * | * | * | * |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
| **ONC Program Funding (continued)**          | > | > | > | > | > | > | > | > |
|                                              |   |   |   |   |   |   |   |   |
|                                              | * | * | * | * | * | * | * | * |
|                                              | * | * | * | * | * | * | * | * |
|                                              | P | I | A | C | P | I | A | C |
|                                              | r | n | d | o | r | n | d | o |
|                                              | i | t | o | l | i | t | o | l |
|                                              | v | e | p | l | v | e | p | l |
|                                              | a | r | t | a | a | r | t | a |
|                                              | c | o | i | b | c | o | i | b |
|                                              | y | p | o | o | y | p | o | o |
|                                              | > | e | n | r | > | e | n | r |
|                                              |   | r | * | a |   | r | * | a |
|                                              | a | a | * | t | a | a | * | t |
|                                              | n | b |   | i | n | b |   | i |
|                                              | d | i |   | v | d | i |   | v |
|                                              | > | l |   | e | > | l |   | e |
|                                              |   | i |   | > |   | i |   | > |
|                                              | S | t |   |   | S | t |   |   |
|                                              | e | y |   | G | e | y |   | G |
|                                              | c | * |   | o | c | * |   | o |
|                                              | u | * |   | v | u | * |   | v |
|                                              | r |   |   | e | r |   |   | e |
|                                              | i |   |   | r | i |   |   | r |
|                                              | t |   |   | n | t |   |   | n |
|                                              | y |   |   | a | y |   |   | a |
|                                              | * |   |   | n | * |   |   | n |
|                                              | * |   |   | c | * |   |   | c |
|                                              |   |   |   | e |   |   |   | e |
|                                              |   |   |   | * |   |   |   | * |
|                                              |   |   |   | * |   |   |   | * |
+----------------------------------------------+---+---+---+---+---+---+---+---+
| **Department of Health and Human Services -  |   |   |   |   |   |   |   |   |
| ONC**                                        |   |   |   |   |   |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
| **ARCHITECTURE AND ADOPTION**                | * | * | * | * | * | * | * | * |
|                                              | * | * | * | * | * | * | * | * |
| Technical Infrastructure Support             | √ | √ | √ | √ | √ | √ | √ | √ |
|                                              | * | * | * | * | * | * | * | * |
| Use Case Development/ Priority Projects      | * | * | * | * | * | * | * | * |
|                                              |   |   |   |   |   |   |   |   |
| Secure Messaging Pilot -- \[FY08 only\]      |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| Nationwide Health Information Network (NHIN) |   |   |   |   |   |   |   |   |
| Architecture                                 |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| EHR Adoption Survey                          |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| Terminology Consensus Project                |   |   |   |   |   |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
|                                              |   |   |   |   |   |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+
| **OPERATIONS**                               | * | * | * | * | * | * | * | * |
|                                              | * | * | * | * | * | * | * | * |
| ONC Staff Operations Support                 | √ | √ | √ | √ | √ | √ | √ | √ |
|                                              | * | * | * | * | * | * | * | * |
| \*Federal Health Architecture (FHA) --       | * | * | * | * | * | * | * | * |
| multi-agency                                 |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| \*Anti-Fraud Activities                      |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| \*AHIC Workgroups                            |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| > \*Federal Interdepartmental Health IT      |   |   |   |   |   |   |   |   |
| > Collaborative -- multi-agency              |   |   |   |   |   |   |   |   |
| >                                            |   |   |   |   |   |   |   |   |
| > \*Federal Interagency Health IT Policy     |   |   |   |   |   |   |   |   |
| > Council -- multi-agency                    |   |   |   |   |   |   |   |   |
|                                              |   |   |   |   |   |   |   |   |
| \[\*These activities are supported by ONC    |   |   |   |   |   |   |   |   |
| Operations Funds or ONC permanent staff\]    |   |   |   |   |   |   |   |   |
+----------------------------------------------+---+---+---+---+---+---+---+---+

**Appendix E: Acronym List**

  ---------------- ------------------------------------------------------
  AHIC             American Health Information Community

  AHIC CPS         AHIC Confidentiality, Privacy & Security Workgroup
  Workgroup        

  AHIMA            American Health Information Management Association

  AHRQ             Agency for Healthcare Research and Quality

  AHLTA            Armed Forces Health Longitudinal Technology
                   Application

  ASPE             Office of the Assistant Secretary for Planning and
                   Evaluation

  ASPR             HHS Office of the Assistant Secretary for Preparedness
                   and Response

  BHIE             Bidirectional Health Information Exchange

  BISTI            Biomedical Computation Science and Technology Grants

  CaBIG            The Cancer Biomedical Informatics Grid

  CaGrid           Infrastructure that supports
                   [caBIG](http://cabig.cancer.gov/)

  CAH              Critical Access Hospitals

  CARE             Continuity Assessment Record & Evaluation

  CCHIT            Certification Commission for Healthcare Information
                   Technology

  CCHT             National Care Coordination Home Telehealth Program

  CDC              Centers for Disease Control and Prevention

  CDS              Clinical Decision Support

  CHDR             Clinical Data Repository/Health Data Repository

  CHI              Consolidated Health Informatics initiative

  CLIA             Clinical Laboratory Improvement Amendments

  CMS              Centers for Medicare & Medicaid Services

  CPHP             The Centers for Public Health Preparedness

  CPOE             Computerized Physician Order Entry

  CPRS             Clinical Patient Record System/ Computerized Patient
                   Record System

  CRS              Computerized Registration System

  CPS              AHIC Confidentiality, Privacy, and Security Workgroup

  CTSA             Clinical and Translational Science Awards

  CVE              Chartered Value Exchange

  DEA              Drug Enforcement Agency

  DHS              Department of Homeland Security

  DoD              US Department of Defense

  EHR              Electronic Health Record

  EMR              Electronic Medical Record

  eRX              Electronic Prescribing

  ESFAC            Epidemiological Surveillance Federal Advisory
                   Committee

  FACA             Federal Advisory Committee Act

  FCC              Federal Communications Commission

  FDA              Food and Drug Administration

  FEHBP            Federal Employees Health Benefit Program

  FHA              Federal Health Architecture

  FHIE             Federal Health Information Exchange

  FMT              Federal Medical Terminology

  FAQ              Frequently Asked Questions

  GWAS             Genome-Wide Association Studies

  Health IT        Health Information Technology

  HHS              US Department of Health and Human Services

  HHS/OS           Office of the Secretary

  HIPAA            Health Insurance Portability and Accountability Act of
                   1996

  HISPC            Health Information Security and Privacy Collaboration

  HITSP            Healthcare Information Technology Standards Panel

  HRSA             Health Resources and Services Administration

  HSPD-21          Homeland Security Presidential Directive 21

  ICD              International Classification of Diseases

  ICD-10-PCS       International Classification of Diseases 10 Procedure
                   Coding System

  IHS              Indian Health Service

  IRB              Institutional Review Board

  IRS              Internal Revenue Service

  ISO              International Organization for Standardization

  LDSI             Laboratory Data Sharing and Interoperability

  LOINC            Logical Observation Identifiers, Names, Codes

  LPGP             Licensure Portability Grant Program

  MCMP             Medicare Management Performance Demonstration

  MMIS             Medicaid Management Information System

  MITA             Medicaid Information Technology Architecture

  NCI              National Cancer Institute

  NCVHS            National Committee on Health and Vital Statistics

  NDBS             Newborn Dried Blood Spot Screening

  NGA              National Governors Association

  NHDSE            National Health Data Stewardship Entity

  NHIN             Nationwide Health Information Network

  NHSN             National Healthcare Safety Network

  NIH              National Institutes of Health

  NIST             National Institute of Standards and Technology

  NCC              National Coordinating Center

  NDW              National Data Warehouse

  NLC              Nurse Licensure Compact

  NLM              National Library of Medicine

  NPIRS            National Patient Information Reporting System

  NRC              The National Resource Center for Health Information
                   Technology

  NQF              National Quality Forum

  OAT              Office for Advancement of Telehealth

  OCR              US HHS Office for Civil Rights

  OIG              Office of the Inspector General of HHS

  OMB              US Office of Management and Budget

  ONC              Office of the National Coordinator for Health
                   Information Technology

  OPM              US Office of Personnel Management

  PAHPA            Pandemic All-Hazards Preparedness Act

  PHIN             Public Health Information Network

  PHR              Personal Health Record

  PHS Corps        Public Health Service Corps

  RFI              Request for Information

  RFP              Request for Proposal

  RHCPP            Rural Health Care Pilot Program

  RHIO             Regional Health Information Organization

  ROI              Return on Investment

  RPMS             Resource and Patient Management System

  RTI              Research Triangle Institute International

  SAMHSA           US Substance Abuse and Mental Health Services
                   Administration

  SARS             Severe Acute Respiratory Syndrome

  TNGP             Telehealth Network Grant Program

  SDO              Standards Development Organizations

  SPL              Structured Product Labeling

  SSA              Social Security Administration

  UMLS             Unified Medical Language System

  UNII             Unique Ingredient Identifiers

  US               United States of America

  USHIK            United States Health Information Knowledgebase

  VA               US Department of Veteran Affairs

  VHA              Veterans Health Administration (within the US
                   Department of Veteran Affairs)

  XML              Extensible Markup Language
  ---------------- ------------------------------------------------------

[^1]: ^\*^ Initial versions of these specifications will be developed by
    the end of Calendar Year 2008.

[^2]: ^\*^ Crossing the Quality Chasm: A New Health System for the
    21^st^ Century. Committee on Quality of Health Care in America,
    Institute of Medicine. National Academy Press. Washington, DC. 2001.
    (Full text available at: [http://www.nap.edu](http://www.nap.edu/)).

[^3]: ^\*\*^ Patient-centered care is defined as care that takes into
    consideration the values and preferences of the patient.

[^4]: ^\*^ All milestone dates should be assumed to refer to the end of
    the designated year.

[^5]: ^1^ An Institutional Review Board (IRB) is a committee made up of
    physicians, statisticians, researchers, community advocates, and
    others that ensures that research done involving human subjects or
    patient information (such as clinical trials) is ethical and that
    the rights of the study participants are protected. For
    HHS-conducted or -supported human subjects research, the human
    subjects regulations at 45 CFR part 46 require that an IRB must
    review and approve such research before its inception, unless the
    research qualifies for a regulatory exemption.

[^6]: ^1^ Internet2 is a U.S. advanced networking consortium, led by the
    research and education community since 1996, which promotes the
    missions of its members by providing both network capabilities and
    partnership opportunities that together facilitate the development,
    deployment and use of Internet technologies.

[^7]: ^2^ The National LambdaRail (NLR) seeks to advance the research,
    clinical, and educational goals of members and other institutions by
    establishing and maintaining a unique nationwide network
    infrastructure that is owned and controlled by the U.S. research
    community.