The Decade of Health Information Technology: 

Delivering Consumer-centric 

and Information-rich Health Care 

Framework for Strategic Action 

July 21, 2004 

Tommy G. Thompson 

Secretary of Health and Human Services 

David J. Brailer, MD, PhD 

National Coordinator for Health Information Technology 

DEPARTMENT OF HEALTH & HUMAN SERVICES Office of the Secretary

National Coordinator for Health 

Information Technology

200 Independence Avenue, SW 

Washington, D.C. 20201

July 21, 2004 

The Honorable Tommy G. Thompson 

Secretary of Health and Human Services 

200 Independence Avenue, SW 

Washington, DC 20037 

Dear Secretary Thompson: 

On April 27, 2004, President Bush called for the majority of Americans to have interoperable 

electronic health records within 10 years, and in doing so signed an Executive Order 

establishing the position of the National Coordinator for Health Information Technology. The 

National Coordinator was charged with developing, maintaining, and overseeing a strategic plan 

to guide nationwide adoption of health information technology in both the public and private 

sectors. The Executive Order also called for the National Coordinator to deliver a report on 

progress toward a strategic plan within 90 days of appointment. 

As the nation’s first National Coordinator, I am pleased to deliver that report to you. Since my 

appointment on May 6, 2004, I have worked with many federal agencies to develop a 

Framework for Strategic Action entitled, "The Decade of Health Information Technology: 

Delivering Consumer-centric and Information-rich Health Care." This Framework outlines 12 

strategies that will achieve four goals critical to the President’s vision. These goals include: 

introduction of information tools into clinical practice, electronically connecting clinicians to other 

clinicians, using information tools to personalize care delivery, and advancing surveillance and 

reporting for population health improvement. 

The President also directed the Department of Veterans Affairs, the Department of Defense, 

and the Office of Personnel Management to report on how they can advance the adoption of 

health information technology. Their reports are attached. Also attached is a comprehensive 

catalogue of identifiable federal health information technology programs. Together, the 

Framework and related reports represent the foundation for rapid adoption of health information 

technology across the nation. 

Thank you for your strong leadership on health information technology. I would also like to 

thank agency heads and key staff for their efforts to develop and support the Framework for 

Strategic Action. 

Regards, 

David J. Brailer, M.D., Ph.D. 

National Coordinator for Health Information Technology 

TABLE OF CONTENTS 

PREFACE........................................................................................................................III

EXECUTIVE SUMMARY ............................................................................................. A

ADDRESSING AN URGENT HEALTH CARE NEED............................................... 1

READINESS FOR CHANGE IN HEALTH CARE...................................................... 2

AVOID MEDICAL ERRORS............................................................................................ 2 

IMPROVE USE OF RESOURCES...................................................................................... 3 

ACCELERATE DIFFUSION OF KNOWLEDGE................................................................... 3 

REDUCE VARIABILITY OF CARE .................................................................................. 4 

ADVANCE CONSUMER ROLE ....................................................................................... 4 

STRENGTHEN PRIVACY AND DATA PROTECTION ......................................................... 5 

PROMOTE PUBLIC HEALTH AND PREPAREDNESS ......................................................... 5 

VISION FOR CONSUMER-CENTRIC AND INFORMATION-RICH HEALTH 

CARE ................................................................................................................................. 6

FRAMEWORK FOR STRATEGIC ACTION.............................................................. 9

INFORM CLINICAL PRACTICE....................................................................................... 9 

Incentivize EHR adoption......................................................................... 10 

Reduce risk of EHR investment................................................................ 14 

Promote EHR diffusion in rural and underserved areas ........................... 15 

INTERCONNECT CLINICIANS...................................................................................... 16 

Foster regional collaborations................................................................... 17 

Develop a national health information network........................................ 18 

Coordinate federal health information systems ........................................ 19 

PERSONALIZE CARE.................................................................................................. 21 

Encourage use of PHRs ............................................................................ 21 

Enhance informed consumer choice ......................................................... 22 

Promote use of telehealth systems............................................................ 23 

IMPROVE POPULATION HEALTH ................................................................................ 23 

Unify public health surveillance architectures.......................................... 24 

Streamline quality and health status monitoring....................................... 25 

Accelerate research and dissemination of evidence.................................. 26 

IMPLEMENTATION .................................................................................................... 27

PUBLIC-PRIVATE LEADERSHIP............................................................................. 29

THE PRIVATE SECTOR ROLE ...................................................................................... 29 

THE FEDERAL ROLE .................................................................................................. 30 

ROLE OF THE NATIONAL COORDINATOR .................................................................. 30 

Provide leadership..................................................................................... 31 

Promote collaboration............................................................................... 31 

i
Develop policy.......................................................................................... 31 

Support financial management ................................................................. 32 

Enhance communication and outreach ..................................................... 32 

Evaluate effectiveness............................................................................... 32 

CONCLUSION ............................................................................................................... 32

BIBLIOGRAPHY........................................................................................................... 34

GLOSSARY OF SELECTED TERMS ........................................................................ 37

LIST OF ATTACHMENTS 

ATTACHMENT 1. REPORT FROM THE OFFICE OF PERSONNEL 

MANAGEMENT 

ATTACHMENT 2. REPORT FROM THE VETERANS ADMINISTRATION 

ATTACHMENT 3. REPORT FROM THE DEPARTMENT OF DEFENSE 

ATTACHMENT 4. FEDERAL HEALTH INFORMATION TECHNOLOGY 

PROGRAMS 

ii
Preface

The Administration and the Department of Health and Human Services (HHS) have 

recognized the importance of fostering the development and diffusion of technology to 

improve the delivery of health care. Over the past few years the federal government and 

the strong, talented leadership of the private sector have made progress in setting the 

stage for transforming health care delivery through vastly improved use of health 

information technology (HIT). 

In 1998, the National Committee on Vital and Health Statistics (NCVHS), a federal 

advisory committee composed of private sector experts, reported that the nation’s 

information infrastructure could be an essential tool for promoting the nation’s health in 

its seminal concept paper, “Assuring a Health Dimension for the National Information 

Infrastructure.” Since that time, other initiatives have helped to further define the best 

approach to apply information and communication technologies to the health sector. 

In 2002, the Markle Foundation organized a public-private collaborative, Connecting for 

Health, which brought together leaders from government, industry, and health care, and 

consumer advocates to improve patient care by promoting standards for electronic 

medical information. A year later, the collaboration of more than 100 public and private 

stakeholders achieved consensus on an initial set of health care data standards and 

commitment for their adoption from a wide variety of national health care leaders. 

In March 2003, the Consolidated Health Informatics (CHI) initiative involving HHS, the 

Departments of Defense (DoD), and Veterans Affairs (VA), announced uniform

standards for the electronic exchange of clinical health information to be adopted across 

the federal health care enterprise. These standards will facilitate information exchange, 

with privacy and security protections, to make it easier for health care providers to share 

relevant patient information and for public health professionals to identify emerging 

public health threats. 

At the end of 2003, President Bush signed into law the Medicare Prescription Drug 

Improvement and Modernization Act (MMA) of 2003. Among other new initiatives, the 

law includes important provisions for HIT. MMA requires the Centers for Medicare and 

Medicaid Services (CMS) to develop standards for electronic prescribing, which will be a 

first step toward the widespread use of electronic health records (EHR). In addition, the 

MMA requires the establishment of a Commission on Systemic Interoperability to 

provide a road map for interoperability standards. 

In April 2004, President Bush issued Executive Order 13335 calling for widespread 

adoption of interoperable EHRs within 10 years, and established the position of National 

Coordinator for Health Information Technology. The Executive Order signed by the 

President directs the National Coordinator to produce a report within 90 days of operation 

on the development and implementation of a strategic plan to guide the nationwide 

implementation of interoperable HIT in both the public and private sectors.

iii
The President’s Information Technology Advisory Committee (PITAC) in June 2004 

issued a draft report, “Revolutionizing Health Care Through Information Technology,” 

which stated that the overall quality and cost-effectiveness of U.S. health care delivery 

bear directly on three top national priorities of national, homeland, and economic 

security. 

In July 2004, Connecting for Health released a timely report that details specific actions 

the public and private sectors can take to accelerate the adoption of information 

technology in health care. Connecting for Health's “Preliminary Roadmap for Achieving 

Electronic Connectivity in Healthcare” contains recommendations in three categories:

creating a technical framework for connectivity, developing incentives to promote 

improvements in health care quality, and engaging the American public by providing 

information to promote the benefits of electronic connectivity and to encourage patients 

and consumers to access their own health information. 

Collectively, these accomplishments have laid the groundwork for a widespread effort to 

drive adoption of interoperable HIT. This report, and the actions that will follow, will 

build upon this foundation to realize the vision for consumer-centric and information-rich 

care. 

This report was published by the Office for the National Coordinator for Health Information Technology (ONCHIT),

Department of Health and Human Services, and the United States Federal Government. 

This report is intended to guide discussion and investigation so progress can be made towards widespread adoption of 

health information technology. This report does not constitute a change in policy nor does it call for statutory changes 

in its own right. 

Specific reports by the Office of Personnel Management (OPM), Department of Defense (DoD), and the Department of 

Veterans Affairs (VA) that respond to the President’s April 27, 2004, Executive Order are also included in this bound 

report. 

The following staff should be acknowledged for their contribution to this report: Clay Ackerly, Kelly Cronin, Lori

Evans, Arlene Franklin, Kathleen Fyffe, Natalie Gravette, Jennie Harvell, Mary Hollander, Lee Jones, Al Kaylani,

Missy Krasner, Barbara Ricks, and Helga Rippen. The efforts of leaders and key staff from each federal agency

involved with this report should be acknowledged. 

iv
The Decade of Health Information Technology: 

Delivering Consumer-centric and Information-rich Health Care

Framework for Strategic Action 

July 21, 2004 

Executive Summary

On April 27, 2004, President Bush called for widespread adoption of interoperable EHRs 

within 10 years, and also established the position of National Coordinator for Health 

Information Technology. On May 6, 2004, Secretary Tommy G. Thompson appointed 

David J. Brailer, MD, PhD, to serve in this new position. The federal government has 

already played an active role in the evolution and use of health information technology 

(HIT), including adoption and ongoing support for standards needed to achieve 

interoperability. Executive Order 13335 requires the National Coordinator to report 

within 90 days of operation on the development and implementation of a strategic plan to 

guide the nationwide implementation of HIT in both the public and private sectors. 

In fulfilling the requirements of the Executive Order, this report outlines a framework for 

a strategic plan that will be dynamic, iterative, and implemented in coordination with the 

private sector. In addition, this report includes attachments from the Office of Personnel 

Management (OPM), the Department of Defense (DoD), and the Department of Veterans 

Affairs (VA). Collectively, this report and related attachments represent the progress to

date on the development and implementation of a comprehensive HIT strategic plan. 

 

Readiness for Change 

There is a great need for information tools to be used in the delivery of health care. 

Preventable medical errors and treatment variations have recently gained attention. 

Clinicians may not know the latest treatment options, and practices vary across clinicians 

and regions. Consumers want to ensure that they have choices in treatment, and when 

they do, they want to have the information they need to make decisions about their care. 

Concerns about the privacy and security of personal medical information remain high. 

Public health monitoring, bioterror surveillance, research, and quality monitoring require 

data that depends on the widespread adoption of HIT. 

Vision for Consumer-centric and Information-rich Care

Many envision a health care industry that is consumer centric and information-rich, in 

which medical information follows the consumer, and information tools guide medical 

decisions. Clinicians have appropriate access to a patient’s complete treatment history,

including medical records, medication history, laboratory results, and radiographs, among 

other information. Clinicians order medications with computerized systems that 

eliminate handwriting errors and automatically check for doses that are too high or too 

low, for harmful interactions with other drugs, and for allergies. Prescriptions are also 

checked against the health plan’s formulary, and the out-of-pocket costs of the prescribed 

drug can be compared with alternative treatments. Clinicians receive electronic 

reminders in the form of alerts about treatment procedures and medical guidelines. This 

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Framework for Strategic Action 

is a different way of delivering health care than that which currently exists, but one that 

many have envisioned. This new way will result in fewer medical errors, fewer 

unnecessary treatments or wasteful care, and fewer variations in care, and will ultimately 

improve care for all Americans. Care will be centered around the consumer and will be

delivered electronically as well as in person. Clinicians can spend more time on patient 

care, and employers will gain productivity and competitive benefits from health care 

spending. 

Strategic Framework 

In order to realize a new vision for health care made possible through the use of 

information technology, strategic actions embraced by the public and private health 

sectors need to be taken over many years. There are four major goals that will be pursued 

in realizing this vision for improved health care. Each of these goals has a corresponding 

set of strategies and related specific actions that will advance and focus future efforts. 

These goals and strategies are summarized below. 

Goal 1: Inform Clinical Practice. Informing clinical practice is fundamental to improving 

care and making health care delivery more efficient. This goal centers largely around 

efforts to bring EHRs directly into clinical practice. This will reduce medical errors and 

duplicative work, and enable clinicians to focus their efforts more directly on improved 

patient care. Three strategies for realizing this goal are: 

− Strategy 1. Incentivize EHR adoption. The transition to safe, more consumerfriendly and regionally integrated care delivery will require shared investments in 

information tools and changes to current clinical practice. 

− Strategy 2. Reduce risk of EHR investment. Clinicians who purchase EHRs and 

who attempt to change their clinical practices and office operations face a variety 

of risks that make this decision unduly challenging. Low-cost support systems 

that reduce risk, failure, and partial use of EHRs are needed. 

− Strategy 3. Promote EHR diffusion in rural and underserved areas. Practices and 

hospitals in rural and other underserved areas lag in EHR adoption. Technology 

transfer and other support efforts are needed to ensure widespread adoption. 

Goal 2: Interconnect Clinicians. Interconnecting clinicians will allow information to be 

portable and to move with consumers from one point of care to another. This will require 

an interoperable infrastructure to help clinicians get access to critical health care 

information when their clinical and/or treatment decisions are being made. The three 

strategies for realizing this goal are:

− Strategy 1. Foster regional collaborations. Local oversight of health information 

exchange that reflects the needs and goals of a population should be developed.

− Strategy 2. Develop a national health information network. A set of common 

intercommunication tools such as mobile authentication, Web services 

architecture, and security technologies are needed to support data movement that 

is inexpensive and secure. A national health information network that can 

provide low-cost and secure data movement is needed, along with a public-private 

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Framework for Strategic Action 

oversight or management function to ensure adherence to public policy 

objectives. 

− Strategy 3. Coordinate federal health information systems. There is a need for 

federal health information systems to be interoperable and to exchange data so 

that federal care delivery, reimbursement, and oversight are more efficient and 

cost-effective. Federal health information systems will be interoperable and 

consistent with the national health information network. 

Goal 3: Personalize Care. Consumer-centric information helps individuals manage their 

own wellness and assists with their personal health care decisions. The ability to 

personalize care is a critical component of using health care information in a meaningful 

manner. The three strategies for realizing this goal are: 

− Strategy 1. Encourage use of Personal Health Records. Consumers are 

increasingly seeking information about their care as a means of getting better 

control over their health care experience, and PHRs that provide customized facts 

and guidance to them are needed.

− Strategy 2. Enhance informed consumer choice. Consumers should have the 

ability to select clinicians and institutions based on what they value and the 

information to guide their choice, including but not limited to, the quality of care 

providers deliver. 

− Strategy 3. Promote use of telehealth systems. The use of telehealth – remote 

communication technologies – can provide access to health services for 

consumers and clinicians in rural and underserved areas. Telehealth systems that 

can support the delivery of health care services when the participants are in 

different locations are needed. 

Goal 4: Improve Population Health. Population health improvement requires the 

collection of timely, accurate, and detailed clinical information to allow for the evaluation 

of health care delivery and the reporting of critical findings to public health officials, 

clinical trials and other research, and feedback to clinicians. Three strategies for realizing 

this goal are: 

− Strategy 1. Unify public health surveillance architectures. An interoperable 

public health surveillance system is needed that will allow exchange of

information, consistent with current law, between provider organizations, 

organizations they contract with, and state and federal agencies. 

− Strategy 2. Streamline quality and health status monitoring. Many different state 

and local organizations collect subsets of data for specific purposes and use it in 

different ways. A streamlined quality-monitoring infrastructure that will allow 

for a complete look at quality and other issues in real-time and at the point of care 

is needed. 

− Strategy 3. Accelerate research and dissemination of evidence. Information tools 

are needed that can accelerate scientific discoveries and their translation into 

clinically useful products, applications, and knowledge. 

Key Actions 

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Framework for Strategic Action 

The Framework for Strategic Action will guide the development of a full strategic plan 

for widespread HIT adoption. At the same time, a variety of key actions that have begun 

to implement this strategy are underway, including: 

Establishing a Health Information Technology Leadership Panel to evaluate the urgency 

of investments and recommend immediate actions

As many different options and policies are considered for financing HIT adoption, the 

Secretary of HHS is taking immediate action by forming a Health Information 

Technology Leadership Panel, consisting of executives and leaders. This panel will 

assess the costs and benefits of HIT to industry and society, and evaluate the urgency of 

investments in these tools. These leaders will discuss the immediate steps for both the 

public and private sector to take with regard to HIT adoption, based on their individual 

business experience. The Health Information Technology Leadership Panel will deliver a 

synthesized report comprised of these options to the Secretary no later than Fall 2004. 

 

Private sector certification of health information technology products

EHRs and even specific components such as decision support software are unique among 

clinical tools in that they do not need to meet minimal standards to be used to deliver 

care. To increase uptake of EHRs and reduce the risk of product implementation failure, 

the federal government is exploring ways to work with the private sector to develop 

minimal product standards for EHR functionality, interoperability, and security. A 

private sector ambulatory EHR certification task force is determining the feasibility of

certification of EHR products based on functionality, security, and interoperability. 

Funding community health information exchange demonstrations 

A health information exchange program through Health Resources and Services 

Administration, Office of the Advancement of Telehealth (HRSA/OAT) has a 

cooperative agreement with the Foundation for eHealth Initiative to administer contracts 

to support the Connecting Communities for Better Health (CCBH) Program totaling $2.3 

million. This program is providing seed funds and support to multi-stakeholder 

collaboratives within communities (both geographic and non-geographic) to implement 

health information exchanges, including the formation of regional health information 

organizations (RHIOs) to drive improvements in health care quality, safety, and 

efficiency. The specific communities that will receive the funding through this program 

will be announced and recognized during the Secretarial Summit on July 21. 

Planning the formation of a private interoperability consortium 

To begin the process of movement toward a national health information network, HHS is 

releasing a request for information (RFI) in the summer of 2004 inviting responses 

describing the requirements for private sector consortia that would form to plan, develop, 

and operate a health information network. Members of the consortium would agree to 

participate in the governance structure and activities and finance the consortium in an 

equitable manner. The role that HHS could play in facilitating the work of the 

consortium and assisting in identifying the services that the consortium would provide 

will be explored, including the standards to which the health information network would 

d 
Framework for Strategic Action 

adhere to in order to ensure that public policy goals are executed and that rapid adoption 

of interoperable EHRs is advanced. The Federal Health Architecture (FHA) will be 

coordinated and interoperable with the national health information network.

Requiring standards to facilitate electronic prescribing 

CMS will be proposing a regulation that will require the first set of widely adopted eprescribing standards in preparation for the implementation of the new Medicare drug 

benefit in 2006. When this regulation is final, Medicare Prescription Drug Plan (PDP) 

Sponsors will be required to offer e-prescribing, which will significantly drive adoption 

across the United States. Health plans and pharmacy benefit managers that are PDP 

sponsors could work with RHIOs, including physician offices, to implement private 

industry-certified interoperable e-prescribing tools and to train and support clinicians. 

Establishing a Medicare beneficiary portal

An immediate step in improving consumer access to personal and customized health 

information is CMS' Medicare Beneficiary Portal, which provides secure health 

information via the Internet. This portal will be hosted by a private company under 

contract with CMS, and will enable authorized Medicare beneficiaries to have access to 

their information online or by calling 1-800-MEDICARE. Initially the portal will 

provide access to fee-for-service claims information, which includes claims type, dates of 

service, and procedures. The pilot test for the portal will be conducted for the residents 

of Indiana. In the near term, CMS plans to expand the portal to include prevention 

information in the form of reminders to beneficiaries to schedule their Medicare-covered 

preventive health care services. CMS also plans to work toward providing additional 

electronic health information tools to beneficiaries for their use in improving their health. 

Sharing clinical research data through a secure infrastructure 

FDA and NIH, together with the Clinical Data Interchange Standards Consortium

(CDISC), a consortium of over 40 pharmaceutical companies and clinical research 

organizations, have developed a standard for representing observations made in clinical 

trials called the Study Data Tabulation Model (SDTM). This model will facilitate the 

automation of the largely paper-based clinical research process, which will lead to greater 

efficiencies in industry and government-sponsored clinical research. The first release of 

the model and associated implementation guide will be finalized prior to the July 21 

Secretarial Summit and represents an important step by government, academia, and 

industry in working together to accelerate research through the use of standards and HIT. 

Commitment to standards

A key component of progress in interoperable health information is the development of

technically sound and robustly specified interoperability standards and policies. There 

have been considerable efforts by HHS, DoD, and VA to adopt health information 

standards for use by all federal health agencies. As part of the Consolidated Health 

Informatics (CHI) initiative, the agencies have agreed to endorse 20 sets of standards to 

make it easier for information to be shared across agencies and to serve as a model for the 

private sector. Additionally, the Public Health Information Network (PHIN) and the 

National Electronic Disease Surveillance System (NEDSS), under the leadership of the 

e 
Framework for Strategic Action 

Centers for Disease Control and Prevention (CDC), have made notable progress in 

development of shared data models, data standards, and controlled vocabularies for 

electronic laboratory reporting and health information exchange. With HHS support, 

Health Level 7 (HL7) has also created a functional model and standards for the EHR. 

Public-Private Partnership 

Leaders across the public and private sector recognize that the adoption and effective use 

of HIT requires a joint effort between federal, state, and local governments and the 

private sector. The value of HIT will be best realized under the conditions of a 

competitive technology industry, privately operated support services, choice among 

clinicians and provider organizations, and payers who reward clinicians based on quality. 

The Federal government has already played an active role in the evolution and use of 

HIT. In FY04, total federal spending on HIT was more than $900 million. Initiatives 

range from supporting research in advanced HIT to the development and use of EHR 

systems. Much of this work demonstrates that HIT can be used effectively in supporting 

health care delivery and improving quality and patient safety. 

Role of the National Coordinator for Health Information Technology 

Executive Order 13335 directed the appointment of the National Coordinator for Health 

Information Technology to coordinate programs and policies regarding HIT across the 

federal government. The National Coordinator was charged with directing HIT 

programs within HHS and coordinating them with those of other relevant Executive 

Branch agencies. In fulfillment of this, the National Coordinator has taken responsibility 

for the National Health Information Infrastructure Initiative (NHII), the FHA, and the 

Consolidated Health Informatics Initiative (CHI), and is currently assessing other health 

information technology programs and efforts. In addition, the National Coordinator was 

charged with coordinating outreach and consultation between the federal government and 

the private sector. As part of this, the National Coordinator was directed to coordinate 

with the National Committee on Vital Health Statistics (NCVHS) and other advisory 

committees. 

The National Coordinator will collaborate with DoD, VA, and OPM to encourage the 

widespread adoption of HIT throughout the health care system. To do this, the National 

Coordinator will gather and disseminate the lessons learned from both DoD and VA in 

successfully incorporating HIT into the delivery of health care, and facilitate the 

development and transfer of knowledge and technology to the private sector. OPM, as the 

purchaser of health care for the federal government, has a unique role and the ability to 

encourage the use of EHRs through the Federal Employees Health Benefits Program, and 

the National Coordinator will assist in gaining the complementary alignment of OPM 

policies with those of the private sector. 

Reports from OPM, DoD, and VA

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Framework for Strategic Action 

The Executive Order also directs the OPM, the DoD, and the VA to submit reports on 

HIT to the President through the Secretary of Health and Human Services. These reports 

are included in this report as Attachments 1 through 3. 

OPM administers the Federal Employees Health Benefits Program for the federal 

government and the more than eight million people it covers. As the nation’s largest 

purchaser of health benefits, OPM is keenly interested in high-quality care and 

reasonable cost. The adoption of an interoperable HIT infrastructure is a key to 

achieving both. OPM is currently exploring a variety of options to leverage its purchasing 

power and alliances to move the adoption of HIT forward. OPM will be strongly 

encouraging health plans to promote the early adoption of HIT. Details on these options 

can be found in OPM’s report, “Federal Employees Health Benefits Program Initiatives 

to Promote the Use of Health Information Technology” (Attachment 1). 

The VA, collaboratively with DoD, provides joint recommendations to address the 

special needs of these populations (Attachment 2). As mirrored in the DoD Report 

(Attachment 3), these recommendations focus on the capture of lessons learned, the 

knowledge and technology transfers to be gained from successful VA/DoD data 

exchange initiatives, the adoption of common standards and terminologies to promote 

more effective and rapid development of health technologies, and the development of 

telehealth technologies to improve care in rural and remote areas. 

The DoD has significant experience in delivering care in isolated conditions such as those 

encountered in wartime or overseas peacekeeping missions, which can be compared to 

the conditions in some rural health care environments. Examples of the technologies 

used in these conditions include telehealth for radiology, mental health, dermatology, 

pathology, and dental consultations; online personalized health records for beneficiary 

use; bed regulation for disaster planning; basic patient encounter documentation; 

pharmacy, radiology, and laboratory order entry and results retrieval for use in remote 

areas and small clinics; pharmacy, radiology, and laboratory order entry and results 

retrieval; admissions and discharges; appointments for use in small hospitals; and online 

education offerings for health care providers. Technology products, outcomes, benefits, 

and cumulative knowledge will be shared for use within the private sector and local/state 

organizations to help guide their planning efforts (see Attachment 3 for more details). 

The VA’s report, “Approaches to Make Health Information Systems Available and 

Affordable to Rural and Medically Underserved Communities” (Attachment 2), also 

highlights its successful strategy to develop high-quality EHR technologies that remain in 

the public domain. These technologies may be suitable for transfer to rural and medically 

underserved settings. VA’s primary health information systems and EHR (VistA and the 

Computerized Patient Record System [the current system] and HealtheVet-VistA, the 

next generation in development) provide leading government/public-owned health 

information technologies that support the provision, measurement, and improvement of 

quality, affordable care across 1300 VA inpatient and ambulatory settings. The VA 

continues to make a version of VistA available in the public domain as a means of 

fostering widespread development of high-performance EHR systems. The VA is also 

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Framework for Strategic Action 

incorporating the CHI approved standards into its next-generation HealtheVet-VistA. 

Furthermore, the VA is developing PHR technologies such as My HealtheVet, which are 

consistent with the larger strategic goal of making veterans (persons) the center of health 

care. Finally, the VA’s health information technologies, such as bar code medication 

administration, VistA Imaging, and telehealth applications, provide the VA with 

exceptional tools that improve patient safety and enable the increasingly geographically 

dispersed provision of care to patients in all settings. These and other technologies are 

proposed as federal technology transfer options in furtherance of the President’s goals. 

Conclusion 

Health information technology has the potential to transform health care delivery, 

bringing information where it is needed and refocusing health care around the consumer. 

This can be done without substantial regulation or industry upheaval. It can give us both 

better care – care that is higher in quality, safer, and more consumer responsive – and 

more efficient care – care that is less wasteful, more appropriate, and more available. 

The changes that will accompany the full use of information technology in the health care 

industry will pose challenges to longstanding assumptions and practices. However, these 

changes are needed, beneficial, and inevitable. Action should be taken now to achieve 

the benefits of HIT. A well-planned and coordinated effort, sustained over a number of 

years, can deliver results that will better support America’s health care professionals and 

better serve the public. 

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The Decade of Health Information Technology: 

Delivering Consumer-centric and Information-rich Health Care

Framework for Strategic Action 

July 21, 2004 

Addressing An Urgent Health Care Need 

The U.S. health care system has a long and distinguished history of innovation. Basic 

research results are translated into new understanding of disease, better diagnostic tools, 

disease prevention, and innovative treatments. New therapies, procedures, and 

medications are the norm, and Americans have access to unparalleled standards of care 

and technologies that give them a continued stream of new treatment options, 

medications, and other therapies over their lifetimes. 

At the same time, health care faces major challenges. Health care spending and health

insurance premiums continue to rise at rates much higher than the rate of general 

inflation. Despite national health care spending of $1.7 trillion (Centers for Medicare and 

Medicaid Services, Office of the Actuary, 2004), concerns persist about preventable 

errors, uneven health care quality, and poor communication among physicians and 

hospitals. The Institute of Medicine (IOM) estimates that between 44,000 and 98,000 

Americans die each year from inpatient medical errors. (Corrigan et al., 2000). 

These problems – high costs, medical errors, variable quality, administrative 

inefficiencies, and lack of coordination – are closely connected to inadequate use of HIT 

as an integral part of medical care. The innovation that has made American medical care 

the world’s best has not been applied to its health information systems. With this in mind, 

President Bush has made transforming health care through HIT a top priority for the 

United States. On April 27, 2004, the President announced his HIT initiative, setting a 

broad goal that most Americans should have electronic medical records within 10 years. 

This vision for the development and implementation of a nationwide interoperable HIT 

infrastructure was further detailed in Executive Order 13335, which also directed the 

appointment of a National Coordinator for Health Information Technology. 

The National Coordinator will lead the nation’s effort to achieve the common goal of

using information technology to improve the affordability, safety, and accessibility of

health care in America. The National Coordinator was directed to develop a nationwide 

strategic plan for HIT adoption. The strategic plan will guide federal agencies and the 

private industry in their efforts to develop and implement programs that will promote the 

adoption of interoperable HIT. A first step in preparing that strategic plan is the release 

of this framework. The National Coordinator and this strategic framework will serve to 

move the nation from a long period of contemplation about HIT to a vigorous stage of 

action and progress in the public and private sectors on this issue. The efforts described in 

this report are aimed at promoting a more effective marketplace, greater competition, and 

increased choice for consumers through wider availability of information on health care 

costs, quality, and safety. 

1 
Framework for Strategic Action 

This framework is intended to guide discussion, investigation, and experimentation so 

that progress can be made towards widespread adoption of HIT. This report does not 

constitute a change in policy, rule, or law, and does not call for statutory changes in its 

own right. 

Readiness for Change in Health Care 

Stakeholders involved in the delivery of health care in the U.S. recognize the critical role 

of HIT in making health care safer and more efficient by enabling complete, accurate, 

and timely information at the point of care for both clinicians and consumers. Each of 

these groups understands that HIT is critical to delivering safe, affordable, and consumeroriented health care, as well as helping to mitigate public health and bioterror threats. 

This consensus results from the convergence of a variety of issues that shape the reality 

of health care today. Arising from this is a new paradigm for care that is built upon seven 

critical needs: 

− Avoid medical errors; 

− Improve use of resources; 

− Accelerate diffusion of knowledge; 

− Reduce variability in access to care; 

− Advance consumer role; 

− Strengthen privacy and data protection; and 

− Promote public health and preparedness. 

Each of these needs is summarized in the sections below. 

Avoid medical errors 

The IOM has estimated that 44,000 to 98,000 deaths occur each year as a result of 

preventable medical errors in hospitals. Additional research has shown that over 770,000 

people are injured or die each year in hospitals from adverse drug events (Classen 1997, 

Cullen 1997, Cullen 1995). Consumers are vulnerable to errors when they receive care 

from multiple sites, so the lack of timely exchange of information has been a 

longstanding safety and quality concern among clinicians. Many new efforts are under 

way to evaluate and address medical errors, including the use of HIT, but new techniques 

and strategies are needed. 

There is growing evidence that the use of HIT improves consumer safety, quality, and 

continuity of care. There is consistent evidence that errors can be reduced by the 

appropriate use of computerized provider order entry (CPOE) and decision support 

systems (DSS), particularly in the case of drug prescribing, dispensing, and 

administration. For example, at LDS Hospital in Salt Lake City, a CPOE system reduced 

adverse drug events by 75% (Evans et al., 1998). Also, at the Regenstrief Institute for 

Health Care in Indianapolis, researchers demonstrated that automated computerized 

reminders increased orders for recommended interventions from 22% to 46% (Overage et 

al., 1997). A 1998 systematic review of the literature assessing the effects of 68 

computer-based clinical DSS demonstrated a beneficial impact on physician performance 

2 
Framework for Strategic Action 

in 43 of 65 studies, and a beneficial effect on patient outcomes in 6 of 14 studies (Hunt et 

al., 1998). A new pharmacy software system implemented by DoD in 2001 that 

integrates and reviews information from all sources prior to prescriptions being filled has 

eliminated over 100,000 adverse drug interactions. 

Improve use of resources 

The United States spent an estimated $1.7 trillion on health care in 2003, and increases in 

health care spending continue to surpass increases in the rate of inflation. As new 

treatments and diagnostic tools are developed, the population ages, and demand increases 

for more specialized and intensive services, America will need innovative costcontainment tools. Studies have shown that nearly 30% of health care spending, or up to 

$300 billion each year, is for treatments that may not improve health status, may be 

redundant, or may be inappropriate for the patient’s condition (Wennberg et al., 2002, 

Wennberg et al., 2004; Fisher et al., 2003, Fisher et al., 2003). 

Some studies estimate that HIT has the potential to reduce inefficient use of resources. 

These studies demonstrate that use of EHRs can reduce laboratory and radiology test 

ordering by 9% to 14% (Bates et al., 1999; Tierney et al.,1987, 1990), lower ancillary 

test charges by up to 8% (Tierney et al,. 1988), reduce hospital admissions, costing an 

average of $16,000 each, by approximately 2% (Jha 2001), and reduce excess medication 

usage by 11% (Teich et al., 2000). While these studies are encouraging, more work 

needs to be done to determine the economic benefits of HIT. This work is corroborated 

by findings in the DoD and VA, where the use of the CPOE has largely eliminated lost 

laboratory reports and pharmacy and radiology orders and the duplication of tests. 

Two studies have estimated that ambulatory EHRs could potentially save $78 billion to 

$112 billion annually, across all payers. This estimate includes $44 billion in annual 

savings from ambulatory EHRs (Johnston, et al., 2003) and $78 billion annually from

interoperability of those EHRs, totaling $112 billion per year (Pan et al., 2004). There is 

also evidence that EHRs can reduce administrative inefficiency and paper handling 

(Khoury, 1998). These studies, while limited in number and scope, suggest that 

economic benefits of HIT could be large, and that further work is needed to determine the 

magnitude of these benefits. 

Accelerate diffusion of knowledge 

Medical knowledge is rapidly changing from breakthroughs, such as those in molecular 

biology, that accelerate the introduction of new medications. However, even wellsynthesized knowledge faces many hurdles to being used in clinical practice. Estimates 

are that, on average, it takes 17 years for evidence to be integrated into clinical practice 

(Balas et al., 2000). Because of the enormous amount of information available, health 

care professionals find it increasingly difficult to keep current with new findings in their 

clinical practices. Research has shown that physicians incorporate the latest medical 

evidence into their treatment decisions 50% of the time (McGlynn et al., 2003). 

3 
Framework for Strategic Action 

When clinical knowledge is coupled with HIT through electronic reminders and other 

context-sensitive workflow, positive changes in practice have been observed. For 

example, a health information system used more than 20 years ago at Massachusetts 

General Hospital showed improved quality of care when reminders were provided to 

physicians (Barnett et al., 1978). Other studies have suggested that physicians who 

receive electronic clinical reminders follow medical evidence more frequently than 

physicians who do not receive these reminders. (AHRQ, Research in Action, 2002.) 

Reduce variability of care 

Many studies have demonstrated that geographic location is a strong determinant of 

specialty care access and procedural decision making (Wennberg et al., 2002). These 

variations in regional patterns are principal determinants of differences in health status

across rural and urban populations. 

While specialty care oversupply in urban areas is linked to higher costs, rural areas lack 

specialists. Advances in telehealth allow physicians to consult each other or to 

communicate with patients and remotely perform other diagnostic and therapeutic 

services. These technologies allow patients to be seen by the best specialist for their 

illness, regardless of where they live. They also enable physicians in rural and 

underserved areas to keep their knowledge current via distance education. Telehealth 

projects in such areas as home health and chronic disease management have shown 

significant cost savings for health care systems. Therefore, improvements in the use and 

commonality of information technology should only further improve the practice of 

telemedicine. 

Advance consumer role 

Consumer expectations for health care are particularly important in today’s environment. 

Consumers often lack information to understand their treatment choices or to select 

physicians and other clinicians appropriate for their needs, and they do not like to fill out 

forms with repetitive information. Consumers report that they often do not feel that they 

are the principal decision maker for their health care and may feel instead that critical 

choices are being made by their clinician or their health plan. 

Advances are being made in bringing consumers directly into decision-making roles 

regarding their care, many using HIT. One study (Fox et al., 2003) reported that 52 

million Americans access health or medical information on the Web. Increasingly, 

consumers are accessing health information via the Web. The National Library of 

Medicine’s MEDLINE is accessed by consumers as frequently as by health care 

professionals and researchers. Consumers most commonly use MEDLINE to access 

information about specific conditions or diseases (e.g., diabetes, asthma, cancer, etc.) and 

medications (e.g., Celebrex). 

Within the federal government, the VA is beginning to engage veterans by providing 

them with a personal health record (PHR) called My HealtheVet. My HealtheVet is a

4 
Framework for Strategic Action 

secure, Web-based PHR system that allows veterans access to key parts of their VA 

health record and to view and update their own health information. The DoD also 

provides a similar resource with TRICARE Online (TOL). TOL is the enterprise-wide, 

secure Internet portal that is used by DoD beneficiaries, providers, and managers 

worldwide to access available health care services, benefits, and information. 

Consumers are also beginning to have access to information about the performance of 

their clinicians so that they can select those who best meet their needs. For example, 

CMS now provides consumers with information about the quality of nursing home and 

home health providers, and is working to make hospital quality measures available as 

well. The National Committee for Quality Assurance (NCQA), through its online tools, 

posts comparative information about physicians, health plans, hospitals, and other 

providers. 

Strengthen privacy and data protection 

Since the enactment of the Health Insurance Portability and Accountability Act of 1996 

(HIPAA), there has been heightened awareness by stakeholders of the need for strong 

privacy and security protections for identifiable health information. Federal standards 

adopted pursuant to HIPAA for privacy and security protections for individually 

identifiable health information have and will continue to strengthen the privacy and 

security of health information within the health care industry and to prevent potentially 

harmful practices and the effects of the inappropriate disclosure of this information. With 

the increasing use of HIT to manage and exchange information in the clinical setting, 

maintaining and improving consumer confidence in the privacy and security of their 

health information will continue to be essential to the success of these efforts. 

HIT, despite fear that it poses risks for the dissemination of health information, may in 

many ways provide better controls over information by providing more privacy and 

security for health information than paper-based medical records. Efforts to protect paper 

records may come at the cost of the portability. However, EHRs have the potential to 

provide a less burdensome means of meeting HIPAA privacy and security standards of 

providing and limiting access to records and of tracking who has had access to consumer 

information on an individual’s specific health record. Building on these, the VA and the 

DoD are actively collaborating on enhancing security standards that enable the protection 

and security of health data, including identification, confidentiality, integrity, 

authentication, and certification. The baseline for this security was laid out in the HIPAA 

security rule. 

Promote public health and preparedness 

Whether in response to disease outbreaks spread through global travel or declining 

immunity, or from man-altered pathogens that intend to produce disease and death, the 

ability to monitor and react to outbreaks is important. However, much real-time 

information is needed to detect and pinpoint an outbreak, and this information requires 

marked changes in how health care information is collected, stored, and exchanged. 

5 
Framework for Strategic Action 

There have been significant improvements in preparedness. Substantial investments are 

being made to get health information for public health and preparedness. DoD is 

providing discrete and aggregated data and forwarding diagnosis information to the 

Centers for Disease Control and Prevention (CDC) for study and analysis. In an average 

week, DoD forwards the ICD-9 and geographic information for 890,000 medical 

encounters, enhancing the CDC’s ability to perform symptom surveillance in support of 

homeland defense and public health. 

Vision for Consumer-centric and Information-rich Health Care 

The President has set an overarching vision for improving the quality, safety, and service 

of health care, and also for using health care resources more efficiently. This vision can 

be realized by making the health care industry consumer-centered and information rich, 

where information that is required for good decision making is available whenever and 

wherever care is provided. To do this, consumer information needs to follow the 

consumer. Basic information such as past medical history, laboratory results, radiographs, 

and current diagnoses, as well as history of medications and treatments, should all be 

available at the bedside or in the physician’s office at the time of care. This information 

would be available to consumers and clinicians at the point of care whenever and 

wherever they need them and no matter where it was originally gathered. . Sophisticated 

decision-support tools that help identify treatments that are best suited to a given patient 

would be available to help reduce unnecessary treatments and to ensure prevention 

procedures, both of which result in better outcomes. Medications would be ordered with 

computerized systems that eliminate handwriting errors and automatically check for 

doses that are too high or too low. Information tools would also search for harmful 

interactions with other drugs and for allergies. Prescriptions would be checked against 

the health plan’s formulary, and the out-of-pocket costs of the prescribed drug would be 

compared with alternative medications. Patient information would be readily available 

for clinicians at the point of care and would help patients improve their own care. 

This is a different way of delivering health care that which currently exists, but one that 

many have envisioned. In this health care system, everyone will benefit by: 

− Fewer medical errors. People being treated for an illness would not have to face 

the risk of being harmed by an error. The majority of medical errors would be 

prevented. Physicians and other authorized clinicians would be able to get up-todate information on their patients and would have instant access to breaking news 

in science and research, and to medical guidelines for treatment. They would 

know which treatments are the most beneficial to their patients at the time they 

were making their clinical decisions. Overall, clinicians would be able to spend 

the majority of their time supporting and treating their patients, and not looking 

for information, waiting for returned phone calls, or facilitating administrative 

functions to deliver care. 

− Less variation in care. Consumers would be able to access and compare the 

quality of clinical services regardless of their geographic location, socioeconomic 

status, disease condition, or disability. This health care would be culturally 

6 
Framework for Strategic Action 

sensitive, technologically advanced, and would emphasize timely access to 

specialists and enhanced clinical decision support so that no consumer or family 

would experience unnecessary delays in access to care. 

− Consumer-centered care. Consumers would have ready access to their personal 

medical information, as well as details on the cost, quality, and service ratings of 

the care they were receiving or seeking.. This type of information would 

maximize consumer choice and involvement in health care and treatment 

decisions. Consumers would also be able to access their treatment information so 

that they could make better decisions and take more control over their health 

status, maintenance, and treatments. Patients could specify their treatment 

preferences and make these preferences readily available to authorized care 

providers. 

− Medical information moves with consumers. As they move from clinician to 

clinician, patients’ information would move seamlessly with them. Clinicians 

would be optimally informed about their patients, and patient care would not be 

interrupted or compromised. This would reduce the need for duplicate tests and 

redundant orders, and eliminate clinical guesswork when a new patient receives 

treatment. 

− Care is delivered electronically as well as in person. As clinical practice enters 

into the information technology age, information should be available to clinicians 

whenever and wherever it is needed. Telemedicine should be used to enhance 

access to the best specialists when they are needed for a specific disease or

treatment. 

− Medical records are protected from unauthorized access. An information-rich 

health care system will make information electronically available that can support 

treating patients, making information accessible for public health and research, 

and improving care for all. This information has been and will be safeguarded in 

order to prevent unauthorized access to personal health data and to prevent 

improper uses and disclosures of individually identifiable information. This 

information would then be used for quality improvement, health services, 

scientific and genomic research, biosurveillance and response, and disaster 

recovery activities. 

− Clinicians can spend more time on patient care. Clinicians should be able to 

focus on care delivery. Care delivery will be enriched by having the most relevant 

information – including up-to-date medical evidence – at the point of care. 

Clinicians and consumers will have more time together free of distractions such as 

searching for traditional paper records. The reporting that every clinician has to 

do should be accurate and timely, but also simple and automated. The data 

needed to conduct research on health care improvement, improve quality and 

efficiency, and monitor disease outbreaks should be available with little work and 

distraction to clinicians. 

The steps that need to be taken across the nation are already under way in some places. 

In the past three years, many communities, hospitals, clinicians, and consumer groups 

have taken the initiative and demonstrated breakthroughs in improving the health care 

system. In these communities, even at this early stage, the process of health care is being 

7 
Framework for Strategic Action 

modernized – and the experiences of both clinicians and consumers are better because of 

the changes. Here are some examples: 

− When arriving at a physician’s office, a new patient does not have to enter his or 

her personal information, allergies, medications, or medical history, since this 

information is already available. 

− A father, who previously had to carry his chronically ill daughter’s medical 

records and x-rays in a large box when seeing a new consultant, can now keep his 

daughter’s important medical history on a key chain drive that plugs into a USB 

port on a computer. 

− Arriving at an emergency room, a senior citizen with chronic illness and memory 

difficulties authorizes her physicians to access her medical information from a 

recent hospitalization at another facility, thus avoiding a potentially fatal drug 

interaction between the planned treatment and the patient’s current medications. 

− While at home, a physician receives a call from a worried mother about her infant 

son and can access, via a secure network, recent lab tests and x-rays online 

instantly, avoiding a trip to the emergency room. 

− While with a patient, a physician enters a prescription on a computer, where 

potential allergies and contraindications are shown immediately, and managed 

care authorization occurs instantly. 

− Clinicians in rural emergency departments routinely send radiology studies to 

university radiologists and receive telephone consultation regarding these studies 

within minutes. 

− Because of worsening angina, a senior citizen is being evaluated by her physician, 

who decision support to augment clinical decision making, and concludes that 

the patient’s life expectancy would be safely extended by angioplasty. 

− At home, a senior citizen consults an online database of physicians to assist in 

choosing a physician to perform an angioplasty for her angina. 

− An intensive care specialist remotely monitors intensive care units in several 

different hospitals, providing coverage 24 hours a day, 7 days a week, reducing 

mortality, length of stay, and total cost of the ICU stay. 

− A small number of cases of an unusual, sudden-onset fever and cough are 

instantly reported to public health officials from area emergency rooms, alerting 

authorities of a possible disease outbreak. 

− A busy professional with a skin rash uses his health plan’s consumer health portal 

to securely e-mail his clinician, who recommends that the patient schedule an 

appointment to be evaluated in person. 

− A soldier returning home from Iraq undergoes a standardized health assessment. 

This information is collected with a personal digital assistant device and sent 

electronically to a central database, where it will be available for review and 

ongoing care in the decades to come by DoD and VA medical providers. 

Automation of the health care industry through widespread use of HIT is a unique means 

of improving quality and reducing costs at the same time. HIT is also critical to 

transforming how health care is delivered. It could allow a real market to develop that 

would reward innovations in care delivery, make the health care system more responsive 

8 
Framework for Strategic Action 

to consumers, and involve consumers much more actively in their own health and health 

care. 

Framework for Strategic Action

Health care that is consumer centered and information rich requires a sustained set of 

strategic actions, embraced by both the public and private health sectors, that need to be 

taken over many years. Four major goals that will be pursued in realizing this vision for 

improved health care are: 

− Inform clinical practice; 

− Interconnect clinicians; 

− Personalize care; and 

− Improve population health. 

The following framework describes each of these goals, along with strategies that will be 

followed to realize the goal and specific actions that pragmatically advance toward the 

goal. As this framework evolves into a full strategic plan, goals and strategies will be 

updated and a variety of new specific actions will be implemented. 

Inform clinical practice 

Fundamental to the goal of improving care and making health care delivery more 

efficient is providing complete and useful patient information and knowledge to 

clinicians when and where they need it and in a manner linked to selection and ordering 

of tests or therapies for patients. Information technology can enable this end-to-end 

approach to clinical decision making. To do this, several needs must be met. 

Information technology products that work within the unique environment of health care 

should be further innovated. This is particularly true for the EHR, which has the 

potential to deliver substantial value but which relies on a unique relationship between a 

clinician and information technology. Better information about the characteristics of

EHRs will allow for a marketplace where clinicians will better understand their needs and 

the options available. A stronger business case for EHRs among physician buyers is 

required to offset the disincentives for quality and efficiency in current reimbursement. 

Furthermore, clinicians who care for underserved populations, including rural areas, 

require special consideration to ensure that they can make the requisite investments and 

encourage regional referral centers to similarly invest in compatible technology. 

There following three strategies will enable realization of the goal of informing clinical 

practice: 

− Incentivize EHR adoption; 

− Reduce the risk of EHR investment; and 

− Promote EHR diffusion in rural and underserved areas. 

9 
Framework for Strategic Action 

Incentivize EHR adoption 

There are high expectations about the benefits that will be derived from using electronic 

medical records, computerized order entry, and other components of the EHR. Evidence 

is well documented that EHRs can improve patient health status (Kohn, 2000). Several 

studies have demonstrated that EHRs can reduce errors and improve use of medical 

evidence (Kuperman, 2003; Bates et al, 1998; Balas et al, 2000). There is a belief that 

EHRs will induce concomitant changes in workflow, in relationships between physicians 

and patients, and in process control that together will trigger subsequent waves of

positive change, moving health care toward a more modern and consumer-driven model. 

A large gap remains, however, between the promise of EHRs and the capacity and 

willingness of clinicians to use them. Data from EHR adoption studies show only modest 

rates of EHR adoption by hospitals and physician groups. Thirteen percent of hospitals 

in 2002 reported that they used EHRs (HIMSS 2002). Physician office EHR use rates 

reported in 2002 ranged from 14% to a possible high of 28% of practices (Loomis et al, 

2002; HIMSS, AstraZenca, 2002). The most commonly cited barrier to implementation 

of EHRs is insufficient resources or a negative return on investment associated with its 

purchase, implementation, and operation. Because of these concerns, the use of EHRs

remains low, and forecasts do not show substantial trends in adoption over the next few 

years. 

Many health system and physician decision makers believe that EHRs are bad financial 

investments, even if they are also business expenses made necessary by the mission of 

their organizations. Despite the long-term benefits realized by patients, payers, 

purchasers, and society as a whole, physician groups and hospitals may be making 

rational economic decisions when they choose not to invest in EHRs. Hospital and 

physician investments in EHRs are costly, pose substantial risks, and have few benefits 

for economic buyers, suggesting that EHR demand is low because the total cost of 

ownership (purchase price, plus implementation, plus maintenance, plus impact on 

operations) is unaffordably high. 

Some of the concerns around EHR adoption are centered on cost because of the upfront 

investment needed for technology and infrastructure, and also because of the high costs 

of managing concomitant clinical and administrative changes. These changes are risky

because the implementations may not succeed, and also because the EHR-driven changes 

in workflow, communication, and decision making threatens physicians and could upset 

the delicate balance between physicians and hospitals, as well as among physicians 

themselves. Some believe that EHRs deliver only a small fraction of their potential 

benefits because the fragmented and volume-based model of health care financing in the 

United States rewards physicians and hospitals for transactions rather than for patient

health status and quality. 

Current adoption of EHRs demonstrates that at least some organizations are realizing

positive economic returns on EHR use, or that they do not require a positive return on

investment to justify purchasing an EHR. The latter organizations may place a high 

10 
Framework for Strategic Action 

financial value on the quality or safety benefits to patients, essentially choosing to fund a 

positive externality in order to fulfill their mission, or they may derive a return from

strategic positioning or market differentiation. However, there are very few physician 

groups or hospitals in the United States able to sustain high capital expenses or operating 

losses over the long term simply because of mission or strategy. For the rest, short-term 

finances will determine whether they invest in EHRs. 

EHRs are a unique category of technology procured by physicians and health systems. 

Like MRIs, for example, they collect a variety of data, summarize data with algorithms, 

store and communicate data, and present data in a manner meaningful to clinicians. Both 

MRIs and EHRs provide information that supplements diagnostic decision making, 

refines choice of treatment, and supplements monitoring of patient progress over time. 

Neither is useful or reliable without a physician’s guidance and oversight. Both can harm

patients if overused, underused, or used improperly, or if they do not perform as 

promised, whether through malfunction, poor maintenance, or design defect. Like MRIs, 

EHRs are very expensive to purchase and operate and have an extended payback period. 

However, EHRs are different from an MRI machine, and nearly every other clinical 

technology, in one notable way: EHRs evolved incrementally into clinical tools from 

their administrative office tool roots, and only recently has sufficient evidence of EHR 

benefit to patient health status been compiled. 

Incentives that might induce EHR adoption or quality and other clinical benefits have 

been discussed for some time. Incentives as a means of stimulating EHR adoption may 

overlook the technical, cultural, and operational barriers to EHR adoption and use. Nonfinancial barriers should and are being addressed. In addition, options for reducing the 

financial disincentives to EHR adoption could also be explored. Options should meet at 

least the following four criteria: 

− Business case improvement. Policy options should consider, in part, the 

economic expense borne by a hospital or physician when purchasing or using an 

EHR. 

− Compatibility with existing programs and regulations. Policy options for EHR 

adoption should be compatible with or incrementally build on existing 

reimbursement and regulations. 

− Budget cost-effectiveness. Policy options should be cost-effective and deliver the 

largest impact for the smallest expenditure. 

− Stakeholder alignment. Policy options should align physicians, hospitals, and 

other stakeholders toward a common goal of improving quality and efficiency. 

HHS will examine many potential policy options for incentivizing EHR adoption, 

including those that might require statutory or regulatory changes for full 

implementation. Among these are the following: 

Regional grants and contracts. HHS will further explore how grants and contracts 

could be made available to regions, states, or communities for EHR adoption and health 

information exchange. In addition to stimulating EHR adoption, this mechanism could 

foster creation of local infrastructures that could support deployment of EHRs and 

11 
Framework for Strategic Action 

oversee data exchange across settings of care. This may improve the business case for 

EHR adoption by physicians and other health care providers and might direct some of 

this investment into regional organizations as well. Up to five state and regional HIT 

demonstration projects will be funded by the Agency for Healthcare Research and 

Quality (AHRQ) in FY04, and an additional $50 million is in the FY05 budget request 

for HHS to continue the support of such projects. This mechanism could align 

community stakeholders toward a common goal of health care improvement. 

Improve the availability of low-rate loans for EHR adoption. The federal government 

could identify possible incentives for the banking and loan industry to provide low-rate 

loans to clinicians and providers that are investing in EHR adoption. This could include 

reducing or removing impediments or barriers to providing such loans. 

Update federal physician self-referral and anti-kickback protections. The physician 

self-referral prohibition and the anti-kickback statute provide important protection against 

fraud and abuse, assuring that taxpayer and beneficiary dollars are spent appropriately 

and preventing patient harm. However, these statutes did not anticipate interoperable HIT 

that necessarily involves relationships among different providers. While the in-kind 

provision of EHRs, hardware, or support by hospitals and other providers or suppliers to 

physicians could accelerate physician adoption of EHRs, this action could face 

unintended conflicts with the physician self-referral prohibition and the anti-kickback 

statute in some circumstances. HHS could explore safe harbors or exceptions to these 

laws that could accelerate EHR adoption without creating inappropriate conflicts of 

interest or potential for abuse. 

Pay for use of EHR. There are two general approaches being explored to reimburse 

clinicians for the use of EHRs that are consistent with current Medicare law. Under the 

physician fee schedule, CMS could consider payment for specific EHR uses though the 

use of new codes or modifiers based on the best estimate of the incremental, amortized 

costs actually incurred by physicians nationwide who use EHRs. Demonstration projects 

could test alternative EHR payment methods, such as direct contracts with physicians, 

and determine whether certain EHRs functionalities or other capabilities could be 

incentivized. 

Pay-for-performance programs. Pay-for-performance would reward clinicians for 

delivering the best quality of care, not the highest volume of care. CMS, under its 

demonstration authority, has the ability to design, implement, and evaluate pay-forperformance programs, above and beyond those planned as a part of implementation of 

MMA. It remains unclear how strongly pay-for-performance programs would accelerate 

EHR adoption, but the effect will likely be dependent on the program design and the 

inclusion of specific EHR criteria within the program. If designed to enable the clinician 

to develop quality management capabilities before stringent performance accountability, 

pay-for-performance programs could enhance EHR adoption and also ensure realization 

of the quality and efficiency value it brings. 

12 
Framework for Strategic Action 

While further analysis and review is needed, it is possible that one or more of these 

mechanisms (or others) could be employed by HHS to stimulate EHR adoption. These 

incentives could be aimed at institutions, clinicians, or both. Clinicians are known to be 

reluctant to adopt EHRs, and hospitals report substantial barriers to EHR adoption that 

arise from physician resistance. Despite their management depth, capital availability, and 

technology experience, hospitals are to some degree dependent on the general views of 

clinicians toward EHRs. Therefore, incentives aimed at professionals might be helpful to 

EHR adoption in physicians’ offices and other ambulatory care sites, but also in hospital 

and other institutional settings as well. 

In order to better understand the value of these options from a societal and industry 

perspective, the Secretary of HHS will take immediate action and convene a Health 

Information Technology Leadership Panel, consisting of executives and leaders. This 

panel will assess the costs and benefits of HIT to industry and society, and evaluate the 

urgency of investment in these tools. These leaders will discuss the immediate steps for 

both the public and private sector to take with regard to HIT adoption. The Health 

Information Technology Leadership Panel will deliver a report to the Secretary no later 

than Fall 2004. 

In addition, HHS and OPM are participating in the recently formed National Alliance for 

Health Care Information Technology Advancement. The Alliance is comprised of 

purchasers and payers representing almost 200 million covered persons. It will work 

together to accomplish the following goals: 

− Identify financial and non-financial incentives that would lower some of the 

current barriers to HIT adoption and use, while recognizing potential cost 

implications for all stakeholders. 

− Explore avenues to share standardized data and contribution to electronic PHRs. 

− Build on the collaborations between all parties to support each other in the 

adoption and implementation of this initiative to advance the quality, safety, and 

efficiency of health care.

HHS will work closely with the Alliance during the next 90 days to identify specific 

strategic actions to meet these goals. 

Beyond its role as a payer, the federal government operates large care delivery networks 

for active military, their families, and retirees through DoD, for eligible veterans through 

VA, and for American Indian/Alaska Native people through the Indian Health Service 

(IHS.) As a purchaser of clinical services, the federal government contracts with private 

sector providers to deliver care to eligible beneficiaries. For VA, these contracts are 

primarily in the area of nursing home and rehabilitative care. The VA recognizes strong 

similarities between the use of incentives within contracting and those within 

reimbursement, so it will align its contract incentives with the reimbursement incentives 

as established by the private and public sectors. IHS has begun leveraging its buying 

power with two major contractor reference laboratories to ensure that Health Level 7 

(HL7) messaging standards are incorporated to ensure bi-directional electronic transfer of 

laboratory orders and results. DoD continues to work closely with the health services and 

13 
Framework for Strategic Action 

support contractors in the areas of privacy, security, and the trusted exchange of health 

information. DoD will also solicit industry’s input regarding potential contracting 

incentives. DoD has already developed contract language to encourage the electronic 

reporting of health data and will consider using the electronic sharing of health data in

future contract evaluation criteria. The full VA report is included as Attachment 2 and 

the DoD report is included as Attachment 3. 

As the nation’s largest employer purchaser of health care benefits for more than 8 million 

people across the United States, the federal government has a strong interest in ensuring 

high-quality care for its employees and annuitants at a reasonable price. OPM is 

exploring a variety of options to leverage its purchasing power to support EHR adoption 

by the providers and networks that deliver services to federal employees, annuitants, and 

their covered family members. OPM will be strongly encouraging health plans to 

promote the early adoption of HIT. The report from OPM is presented in Attachment 1. 

Reduce risk of EHR investment 

Clinicians who purchase an EHR and who attempt to change their clinical practices and 

office operations face a variety of risks that make this decision unduly challenging. 

Implementation failure and partial use of EHRs are commonplace. Even if EHRs are 

implemented, there is no guarantee that they will be used and therefore lead to value for 

clinicians, consumers, or payers. Failed EHR implementation dissipates investment 

capital and leads to cynicism and fear among those who may want to bring their practices 

into a more modern era. 

Implementation risks and the lack of value realization from EHRs limits growth and 

sustainability of the private market for health care information technology. Both buyers 

and sellers can benefit from institutions and agents that support physician buyers when 

they deal with highly capitalized technology companies. These institutions can mitigate 

the risk of EHR implementation failure and can also affect information asymmetry 

between clinicians and vendors when EHRs are being marketed. This will result in more 

cost-effective EHR adoption, less risk-adverse buyers, and a faster-growing and more

attractive market for investments in HIT. 

There are many causes of the risks associated with EHR implementation. One is that 

clinicians lack affordable and skilled support to assist in implementation and workflow 

change. Clinicians need ongoing technical assistance on how to reorganize office 

workflow processes to integrate and utilize EHRs to improve the quality, safety, 

efficiency, and cost in managing care. Support is needed for a wide variety of information 

tools, including registries, e-prescribing, e-labs, PHRs, and a fully integrated EHR. 

However, since many physicians are in small practices that may lack capital and spend 

relatively small sums on EHRs, they cannot easily find these services. ONCHIT will 

encourage private sector organizations to evaluate potential vehicles to provide this 

support on a cost-effective and trusted basis. 

14 
Framework for Strategic Action 

Another risk is faced in product selection. EHRs and even specific components such as 

decision support software are unique among clinical tools in that they do not need to meet 

minimal standards to be used to deliver care. To increase uptake of EHRs and reduce the 

risk of product implementation failure, the federal government is exploring ways to work 

with the private sector to develop minimal product standards for EHR functionality, 

interoperability, and security that will be tied to financial incentives. A private-sector, 

ambulatory EHR certification task force is determining the feasibility of certification of

EHR products based on functionality, security, and interoperability. This task force will 

determine the governance structure for the certification entity that represents the various 

participants in EHR adoption. It will also identify minimal requirements for portable, 

secure, and interoperable health information and develop mechanisms for evaluating 

products against these criteria. 

Promote EHR diffusion in rural and underserved areas 

A gap in EHR adoption between urban and rural practices has been documented. 

Organizational size appears to influence EHR adoption (Lorence et al, 2002) in both 

inpatient and ambulatory settings. Urban practices capture 30% more patient information 

electronically than do rural practices. Interventions that increase overall EHR uptake 

may widen this gap unless protections are established for practices and hospitals in rural 

and other underserved areas. This could result in divergent standards of care based on 

availability of EHR technology. 

The federal government will explore how to address the barriers to EHR adoption in rural 

and underserved areas by using its buying power and specialized technology to improve 

the access to EHRs. DoD and VA operate the largest health care delivery networks in the 

nation. VA has significant experience in delivering care to rural and historically 

underserved veteran populations. DoD has significant experience in delivering care in 

isolated conditions such as those encountered in wartime or overseas peacekeeping 

missions, which can be compared to the conditions in some rural health care 

environments. Furthermore, the need for DoD to transport data to other facilities or 

providers may be similar to the situation with migrant workers. As purchasers of health 

care delivery products and services, these departments have significant experience in 

developing health care information technology acquisition strategies, performance-based 

contracts, negotiated volume discounts, and contract management. DoD and VA will 

draft templates of standard contract language for use nationally that will encourage 

industry to produce products and services that are scalable and applicable to the private 

sector. When selecting potential contractors, acquisition selection criteria could be 

developed that favorably consider those companies that agree to provide products and 

services applicable to targeted communities such as rural and underserved areas. 

To meet the existing business needs of reaching geographically distanced providers and 

consumers, the VA has become a leader in the field of telehealth and telemedicine. VA’s 

strategy for the expansion of telehealth could not take place without the presence of the 

VistA computerized patient record system. Within VA, there is a uniformity of opinion 

that the future of telehealth is within the context of a multimedia patient record. The 

15 
Framework for Strategic Action 

driver for these innovations in VA is not primarily technological; it is instead that 

technology is serving how VA meets the changing nature of the health needs of veterans. 

VA is working with HHS to transfer HIT to the private sector. CMS is funding and 

collaborating with VA and other key federal agencies on the development of a “VistAOffice EHR” version of the VistA system for potential use in clinics and physician 

offices. An overriding goal of VistA-Office EHR is to stimulate the broader adoption 

and effective use of EHRs by making a robust, flexible EHR product available in the 

public domain. The first version of VistA-Office EHR is expected to be available in 

2005. The system will be made available under the Freedom of Information Act, and may 

be used by commercial EHR vendors or installed directly by health care providers. 

Further details of VA activities are reported in Attachment 2. 

DoD has significant experience in delivering care in isolated conditions such as those 

encountered in wartime or overseas peacekeeping missions that can be compared to the 

conditions in some rural health care environments. Examples of the technologies used in 

these conditions include: telehealth for radiology, mental health, dermatology, dental, 

and pathology consultation; online PHRs for beneficiary use; bed regulation for disaster 

planning; basic patient encounter documentation; and pharmacy, radiology, and 

laboratory order entry and results retrieval for use in remote areas and small clinics. The 

full DoD report is presented in Attachment 3. 

IHS can provide another alternative for rural and safety net sites through the next 

generation of the Resource and Patient Management System (RPMS) EHR system. 

Through support from AHRQ, the new RPMS will have an improved graphical-user 

interface that will significantly enhance the functionality of the system. Since the IHS 

system is extensively used in small and rural communities, it has many features that

would support its use in other safety net communities. In addition, since the IHS 

provides care across the life continuum, many functionalities for women and children are 

already available. 

Interconnect clinicians

Without an interoperable infrastructure to allow for the secure movement of health 

information, the adoption and use of EHRs will not realize their full benefits. Indeed,

non-interoperable EHRs could actually impede access and harm care by protecting 

information silos and proprietary control over populations to limit mobility of patients. 

Therefore, it is essential that EHRs are interoperable so that data are portable and can 

follow patients as they move through care settings. 

An interoperable infrastructure requires coordinated and secure health information 

exchange, including the business, governance, and technical delivery mechanisms to 

support it; a set of intercommunication tools, and services for common architecture 

development; the diffusion of product standards into deployed products; privacy and 

security assurances; and connectivity infrastructure. Development of this infrastructure is 

a vital national priority and will require vehicles that can support public and private 

16 
Framework for Strategic Action 

sector investments. An interoperability infrastructure will accelerate the adoption of

EHRs, as well as their use in a way that benefits consumers, purchasers, and society as a 

whole. 

The following three strategies for achieving the goal of interconnecting care are detailed 

below: 

− Foster regional collaborations; 

− Develop a national health information network; and 

− Coordinate federal health information systems. 

Foster regional collaborations 

The development, implementation, and application of secure health information exchange 

across care settings requires a local leadership, oversight, fiduciary responsibility, and 

governance. These regional health information organizations (RHIOs) are critical to 

health information exchange that reflects the health care priorities of a local area as well 

as the legitimacy and trustworthiness of this activity to clinicians and consumers. 

While a few regions, states, or local areas have collaboratives that operate as governance 

entities, such as the Indiana Health Information Exchange, The Share Health Information 

Across Regional Entities project in Massachusetts, and the Santa Barbara County Care 

Data Exchange, there is no systematic basis for regional organization that can serve the 

nation’s health information exchange goals. These local or regional initiatives are under 

way and increasing in number, but they lack coordination, involve poorly funded early 

stage projects, are highly variable, and have not produced a sustainable business model 

for other regions. 

The Foundation for eHealth Initiative’s Connecting Communities for Better Health 

Program, based on a widely disseminated request for capabilities funded by the Health 

Resources and Services Administration, Office of the Advancement of Telehealth 

(HRSA/OAT), found that 134 community-based health information exchange projects 

across 42 states are developing varying types of organizational and operating models. 

To create a more permanent and accountable infrastructure to support health information 

exchange, there is a need for a common approach to the formation and operation of 

RHIOs. The government could help define a common set of practices by incorporating 

minimal performance requirements into its contracts with, or grants to, communities. 

Another approach, commonly used in health care, is private sector accreditation to ensure 

that these organizations meet minimal standards. Nongovernmental accreditation would 

serve a necessary oversight function without undue regulation or requirements. HHS will 

explore how to ensure minimal standardization in conjunction with other federal agencies 

and the private sector. 

Regardless of how RHIOs are overseen, the government can play an important role in 

supporting their formation. One role is to ensure that RHIOs are formed in the major 

17 
Framework for Strategic Action 

market areas and, to the extent possible, in rural areas. Currently, there are two HHS 

programs available to support RHIOs through grants and contracts. 

First, AHRQ is funding State and Regional Health Information Exchange Demonstration 

Projects. AHRQ will fund at least five state-level health information exchange projects 

to build on current state-level planning activities by providing crucial funding, technical 

assistance, and coordination. Further, the regional health information authorities will be 

piloted as critical aspects of the projects to build, operate, and sustain health information 

exchange. AHRQ will announce the states that are awarded contracts in 2004. 

The second HHS health information exchange program is through HRSA/OAT, which 

has a cooperative agreement with the Foundation for eHealth Initiative to administer 

contracts to support the Connecting Communities for Better Health (CCBH) Program 

totaling $2.3 million. This program is providing seed funds and support to multistakeholder collaboratives within communities (both geographic and non-geographic) to 

implement RHIOs that can drive improvements in health care quality, safety, and 

efficiency. The specific communities that will receive the funding through this program

will be announced and recognized during the Secretarial Summit on July 21. 

Develop a national health information network 

Interoperable EHRs and health information exchange requires a set of common standards 

as well as intercommunication tools such as mobile authentication, Web services 

architecture, and security technologies. Many of these technologies exist in other 

industries, but have not been adapted to the unique requirements of health information 

exchange. A national health information network that can provide low-cost and secure 

data movement is needed, along with a public-private oversight or management function 

to ensure adherence to public policy objectives. 

Such a technology should be nonproprietary, available for broad use, and shared within 

the public domain in a manner that is available to all. It should be integrated with public 

health surveillance and response in accordance with existing statutory provisions, and 

deployed and operated in a secure, HIPAA-compliant and decentralized manner. This 

national network will require an investment that is large and risky, and will require the 

coordinated efforts of many technology companies. 

A key component of a national health information network is the development of 

technically sound and robustly specified interoperability standards and policies for 

diffusion into practice. There has been considerable effort and progress achieved by 

HHS and other federal agencies with the adoption of standards across 20 domains by the 

Consolidated Health Informatics (CHI) initiative to allow for the electronic exchange of

clinical health information across the federal government. The National Library of 

Medicine (NLM), AHRQ, FDA, VA, and DoD have been collaborating to promote the 

adoption, mapping, and implementation of key vocabularies such as SNOMED CT and 

RxNorm (a clinical drug vocabulary). Additionally, the Public Health Information 

Network (PHIN) and National Electronic Disease Surveillance System (NEDSS) under 

18 
Framework for Strategic Action 

the leadership of the CDC have made notable progress in the development of shared data 

models, data standards, and controlled vocabularies for electronic laboratory results 

reporting and health information exchange. With HHS support, HL7 has also created a 

functional model and standards for the EHR. 

To begin the process of movement toward a national health information network, HHS is 

releasing a request for information (RFI) in the summer of 2004 inviting responses 

describing the requirements for private sector consortia that would form to plan, develop, 

and operate a health information network. Members of the consortium would agree to 

participate in the governance structure of this privately financed consortium in an 

equitable manner. The role that HHS could play in facilitating the work of the 

consortium and assisting in identifying the services that the consortium would provide 

will be explored, including the standards to which the health information network would 

adhere to in order to ensure that public policy goals are executed and that rapid adoption 

of interoperable EHRs is advanced. The resulting national health information network 

will be coordinated and interoperable with the FHA. 

Also, CMS will be proposing a regulation that will require the first set of widely adopted 

e-prescribing standards in preparation for the implementation of the new Medicare drug 

benefit in 2006. When this regulation is final, Medicare Prescription Drug Plan (PDP) 

sponsors will be required to offer e-prescribing, which will significantly drive adoption 

across the United States. Health plans and pharmacy benefit managers that are PDP 

sponsors could work with RHIOs, including physician offices, to implement private 

industry-certified, interoperable e-prescribing tools and to train and support clinicians. 

A subsequent regulation will be proposed for additional standards necessary to realize the 

full value of e-prescribing, once these standards have been developed and tested in the 

health care system. In parallel with this effort, FDA will work with the pharmaceutical 

industry to develop a structured product label that will use medication standards to enable 

electronic drug information to be available at the point of care when prescribing decisions 

are made. Through collaboration with the NLM, electronic drug information called 

DailyMed will be disseminated free of charge to all information systems. 

Future possible actions by the federal government include security technology transfer by 

the DoD. The DoD has significant experience in developing and implementing common 

and unique infrastructure solutions that provide the foundation for all information 

exchange. DoD is exploring ways to share this experience with private-sector developers 

of interoperability solutions to the extent allowable under current law. Potential areas of 

technology transfer include computing (e.g., computers, databases, and servers) and 

communication (networks, Internet connectivity, and security firewalls) infrastructure 

requirements, which serve as the backbone for exchanging secure information. 

Coordinate federal health information systems 

The federal government maintains a large variety of health information systems that 

support the delivery, management, reimbursement, monitoring, and other aspects of 

19 
Framework for Strategic Action 

patient care. There is a strong need to provide for interoperability and exchange of data 

through these systems so that federal systems are more efficient and cost-effective. 

Additionally, federal health information systems will be coordinated and interoperable 

with the national health information network. There have been early efforts to coordinate 

these systems through the FHA and the CHI, but there is more to be done. The federal 

government operates at least three patient care information systems, multiple claims and 

reimbursement systems, and an undefined number of systems that collect and deliver 

information for federal agencies, or that store, analyze, or communicate this information 

elsewhere. To facilitate the exchange of electronic health information, DoD and VA are 

finalizing a common architecture strategy consisting of standardized data, 

communications, security, and high-performance health information systems. However, 

many systems still cannot communicate among themselves or provide a minimal amount 

of interoperability. 

In the near future, a consortium of federal agencies that are involved in health 

information will make a renewed commitment to the FHA and CHI for the purpose of

achieving internal interoperability. This will be accomplished by refining a blueprint and 

an information architecture for the federal health enterprise. The blueprint will serve as a 

common business reference point from which information technology investment 

decisions can be made. The architecture will enable collaboration and data sharing across 

the government and with various organizations such as states and private entities that 

provide or need federal information. The FHA initiative is the forum to forge unification 

of isolated architectures to develop common pathways of interoperability between 

government agencies. Toward this end, FHA has committees on the EHR, food safety 

and surveillance, and interagency operability under way. All resulting information 

architectures will adhere to the industry standards endorsed by the federal agencies as 

CHI standards. 

The VA and DoD are also actively collaborating and cooperating on security standards, 

consistent with HIPAA security rule and other relevant laws, for the following services: 

identification, authentication, accountability, data integrity, non-repudiation, 

confidentiality, and certification. Confidentiality, security of information, and data 

integrity are fundamental requirements for the successful exchange of information and in 

the evolution of the EHR. 

The VA and DoD Common Security Architecture will contain a framework for 

information assurance (information security and confidentiality) roles and behavior 

among information technology assets, and prescribe rules for interaction and 

interconnection. This architecture must provide for the integrity, confidentiality, and 

authentication of electronic-protected health information (EPHI) as dictated by HIPAA. 

It can serve as a basis for federal enterprise-wide health communications exchange. The 

important work of these departments will be incorporated into the FHA, where both 

departments are leading members. 

20 
Framework for Strategic Action 

Personalize care 

The ability to assemble and use information that is complete with respect to a specific 

person is an essential part of the application of information technology to health care and, 

in many ways, the fullest expression of interoperability. Consumer-centric information 

helps individuals manage their own wellness and assists with their personal health care 

decisions. This information could include consumer-specific health findings, health 

status monitoring tools, or customized prevention and self-care information. Such 

personalized care information could be adapted for diverse individual needs, cultural 

traditions, reading levels, or socioeconomic modulators of illness. The ability to 

personalize care is a critical component of using health care information in a meaningful 

manner. 

The universe of health information that may be accessed by consumers is enormous. 

Tools to synthesize and customize this information are crucial for the discovery and 

presentation of relevant facts in the interest of a given consumer. At present, most of an 

individual’s personal health information is only accessible through a restricted set of 

channels, primarily his/her physician or health plan. Enhancing the information available 

to consumers, making it more relevant or customized to their needs and linking this to 

treatment options, promises to improve the consumer’s participation in care delivery. 

This is particularly true for advances in genetics and genomics that will be key in many 

respects to personalizing health care. Once equipped with the information about their 

health and health care choices, consumers will be empowered to co-manage their health 

and participate actively in decisions about their care. 

Consumers are increasingly seeking customized and better information as a means of 

improving their health status. Increasingly consumers are accessing health information 

via the Internet, and the number of health-related websites has increased. Consumers are 

looking for information that is tailored to their illness or concerns, and want to know how 

advisories, treatment options, risks, or other information relate to themselves. They also 

want to be able to share and discuss this information with their own health care clinicians. 

Three strategies for achieving the goal of personalized care are detailed below: 

− Encourage use of (PHRs); 

− Enhance informed consumer choice; and 

− Promote use of telehealth systems. 

Encourage use of PHRs 

One rapidly emerging trend is the PHR, which maintains individual personal health 

information from a variety of health records, guidelines, and other tools useful to 

consumers. While the specifications for the PHR and its relationship to EHRs have yet to 

be defined, the Connecting for Health Public Private Collaborative, involving the 

American Public as Partners work group, has identified techniques, standards, and 

policies to be employed by developers of PHRs to ensure that information can be 

exchanged between PHRs and other data sources for the patients’ benefit. The group has 

21 
Framework for Strategic Action 

also recommended that demonstration projects should occur to implement these common 

practices. 

The federal government has and will continue to use information technology as a central 

tool and vehicle to disseminate health information and knowledge to consumers. 

Currently, HHS provides health information via the Web, and agencies customize 

information and interactive tools for different types of consumers, including the elderly. 

For example, MedlinePlus, MedlinePlus en Espanol, healthfinder, CDC’s consumer 

health information, and www.4woman.gov, the Office of Women’s Health website, are 

experimenting with different methods of customizing personal health information. In 

particular, the CDC’s new Futures Initiative includes anticipated changes in the CDC’s 

website that will allow for up-to-date prevention and disease information to be integrated 

into clinical care information systems to support just-in-time information delivery and 

reference.

An immediate step in improving consumers' access to personal and customized health 

information is CMS' Medicare Beneficiary Portal, which provides secure health 

information via the Internet. This portal will be hosted by a private company under 

contract with CMS, and will enable authorized Medicare beneficiaries to have access to 

their information online or by calling 1-800-MEDICARE. Initially the portal will 

provide access to fee-for-service claims information, which includes claims type, dates of 

service, and procedures. The pilot test for the portal will be conducted for the residents 

of Indiana. In the near term, CMS plans to expand the portal to include prevention 

information in the form of reminders to beneficiaries to schedule their Medicare-covered 

preventive health care services. CMS also plans to work toward providing additional 

electronic health information tools to beneficiaries for their use in improving their health. 

Enhance informed consumer choice 

Unbiased information about the performance of health care providers empowers 

consumers to make informed choices about where and from whom to receive health care 

treatments. Consumers should be informed about clinicians and institutions based on 

what the consumer values, including, but not limited to, the quality of care that the 

provider has historically delivered. However, efforts to provide reliable and sufficiently 

risk-adjusted measures about health care provider performance have been significantly 

shaped and limited by the availability of robust clinical information. Because of this, 

clinical performance is difficult to compare with certainty, and what is measurable is 

often not what is important in consumer choice. 

CMS has taken a leadership role in promoting consumer choice by providing information 

about the performance of dialysis facilities, nursing homes, and home health agencies on 

its consumer-friendly www.medicare.gov website. Since there was no regulation for 

hospital data reporting, a 10-measure starter set of performance data for heart attack, 

heart failure, and pneumonia has been voluntarily reported as part of the National 

Voluntary Hospital Reporting Initiative (NVHRI) since October 2003. The NVHRI is 

collaborating with the American Hospital Association, the Federation of American 

22 
Framework for Strategic Action 

Hospitals, the Association of American Medical Colleges, the AFL-CIO, JCAHO, and 

others. In February 2005, this information will migrate to Hospital Compare on 

www.medicare.gov for consumers. Content, displays, and formats are now being tested 

with consumers in order to make the information consumer friendly and understandable. 

Promote use of telehealth systems 

The use of telehealth can provide access to health services for consumers and clinicians 

in rural and underserved areas. Telehealth is the delivery of health care services in cases 

where the participants are in different locations, and may even be separated in time. 

Using various forms of telehealth, rural clinicians can, for example, examine a patient’s 

inner ear from a remote location. A patient in a rural emergency room can get the benefit 

of local care in addition to remote consultation with a specialist. A clinician can review a 

radiology scan that was forwarded from a remote location. A patient and nurse can 

interact during a video home visit, and the nurse can check vital signs and monitor 

medication compliance. A patient and clinician can communicate by e-mail to make 

health care decisions without requiring the patient to be in the physician’s office. These 

forms of telehealth provide distance-based support to clinicians or to clinicians and 

patients. 

Research studies have demonstrated the usability and cost savings of telehealth 

applications. Medicare’s reimbursement of telemedicine through the physician fee 

schedule started in January 1999 for several care providers, including physicians, 

physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, 

clinical psychologists, and clinical social workers as well as various types of procedures 

such as consultations, office visits, individual psychotherapy, and pharmacologic 

management. Currently, there are certain limitations on the reimbursement requirements, 

including: a) Only patients located in rural Health Professional Shortage Areas (HPSAs) 

and beneficiaries in counties not defined as a metropolitan statistical area (MSA) are 

eligible for telemedicine reimbursement; b) there are fee-sharing challenges between 

primary care clinicians and specialists; and c) licensed practicing nurses and registered 

nurses are not eligible for reimbursement under Medicare. 

In order to fully use telemedicine as a means of improving care, the Joint Working Group 

on Telehealth (JWGT) provides a forum for federal agencies to coordinate telehealth 

program and policy development. The JWGT membership includes representatives from

every major cabinet agency involved in providing telehealth services, and is staffed by 

the Office for the Advancement of Telehealth, HRSA. Agencies and private-sector

organizations share telehealth expertise and information, educate participants, and take 

actions to increase use of telehealth. Additionally, HRSA has been a leader in promoting 

the advancement of telehealth systems, funding programs and demonstrations since 1988. 

Improve population health 

The improvement of population health requires timely, accurate, and detailed clinical 

information to allow for evaluation of health care delivery. It may include reporting of 

23 
Framework for Strategic Action 

critical findings to public health officials, clinical trials, and other research. Feedback to 

clinicians is also important for improvements in care delivery. However, collection of 

this information cannot impose an undue burden. This is of particular importance as 

assumptions are made about the ability of EHRs to support a new echelon of information 

needs for research and surveillance. 

Significant work has been done by the CDC and state public health agencies to identify 

and implement appropriate standards and establish practices that meet a broad array of 

different population health functions. The benefits of information collection to support 

population health – quality measurement, patient safety, research and clinical trials, 

public health reporting, and biosurveillance – are apparent, but how and under what 

conditions these data should be collected are not. While information required for 

population health needs to be captured by EHRs and exchanged with local, state, and 

federal government to the extent possible under current law, this has to proceed in a 

coherent and collaborative manner. 

The following three strategies will achieve the goal of using HIT to improve the 

population’s health status: 

− Unify public health surveillance architectures; 

− Streamline quality and health status monitoring; and 

− Accelerate discovery and dissemination. 

Unify public health surveillance architectures 

To reduce the risk to public health from hazards such as communicable diseases, unsafe 

imported foods, and terrorism, public health must detect threats soon after they occur, 

investigate the magnitude and nature of the threat, track who is sick, with whom they 

have been in contact, and where they were exposed to the disease or contaminated food. 

Public health officials must also alert health care providers of a confirmed or potential 

threat and deliver relevant information, treatment guidelines, and interventions; support 

countermeasure and response administration, including treatment, prophylaxis, 

vaccination, and isolation; and monitor the response, determine if it was effective, and

apply changes to improve outcomes. Likewise, medical devices and other products need 

to be monitored by trained professionals who can ensure that the device is functioning 

properly and the desired functional result is achieved. 

An interoperable surveillance system will allow exchange of information, consistent with 

current law, among provider organizations, organizations they contract with, and state 

and federal agencies. The key challenge in harmonizing surveillance architectures is to 

identify solutions that meet the reporting needs required for each surveillance function

yet which also work in a single integrated and cost-effective architecture. The current

legal framework for public health surveillance will guide short-term planning efforts to 

integrate architecture. However, as longer-term planning is under way, HHS will explore 

business practices and certain types of secure information exchange for public health 

purposes. These findings may require additional regulations to better protect public 

health. 

24 
Framework for Strategic Action 

HHS is exploring many actions to realize the goal of improving population health. The 

following actions summarize the most important future efforts that could better unify 

architectures to improve surveillance. The government-sponsored standards-setting 

processes, CHI and the FHA, will develop a unified and interoperable infrastructure to 

simplify the surveillance-related data exchange between government agencies and the 

health care delivery system. This will result in consistent, real-time data feeds routed over 

common infrastructure to meet the needs of public health surveillance and response 

functions, and allow for a unified population-health approach that will deliver the best 

care in the most cost-effective manner. As part of this, CDC will work to integrate local 

and state public health surveillance, alerting, knowledge management, and response 

functions using national information systems standards. Public Health Informatics 

Network (PHIN) partnerships with the Department of Homeland Security have 

implemented HL7 lab result reporting for environmental monitoring in over 20 

Laboratory Response Network Labs nationally. Partnerships with the FDA are 

developing HL7 standard messages for food monitoring, and the FDA has also developed 

an HL7-based messaging standard to facilitate automated reporting of product-related 

adverse events from the EHR to improve the frequency and quality of reporting without 

inconveniencing the clinician or causing undue burdens on providers. Similarly, the 

Environmental Protection Agency (EPA) has a mature surveillance system that will 

contribute substantially to the consolidated architecture. 

CDC will also work with local and state public health partners that are involved with 

regional health information projects to ensure that important public health data is 

captured and transmitted, as appropriate, to CDC. BioSense, a new program for 

accelerated early detection of bioterrorist or naturally occurring outbreaks, will work with 

AHRQ-funded state demonstration programs starting in 2004 to plan for the provision of 

health event data for use in detecting, localizing, and then investigating emerging disease 

events. BioSense is now receiving standards-based health event data from DoD and VA 

health care facilities.

Streamline quality and health status monitoring 

Aggregated and de-identified individual health care data have a critical role in monitoring 

population health status and clinical quality at the point of care. These data can be used 

to detect and address quality variations, to enable consumer choice, and for many other 

functions. They can support pay-for-performance programs and other means of 

rewarding outstanding quality. When aggregated and analyzed, timely and detailed 

clinical data can improve care in a community or the whole nation by rationalizing the 

allocation of resources, steering new research, and enhancing clinician training. Many 

different state and local organizations collect subsets of data for specific purposes and use 

them in different ways. A streamlined quality-monitoring infrastructure will allow for a 

complete look at quality and other issues in real-time and at the point of care, while also 

minimizing intrusions and burdens imposed on clinicians. 

25 
Framework for Strategic Action 

Population health status monitoring can also benefit from widespread adoption of EHRs 

and PHRs. CDC currently receives health status data from many sources, including 

population-based surveys, vital statistics, and administrative datasets. EHRs and PHRs 

have the potential to supplement conventional reporting and monitoring through direct 

electronic data acquisition. 

HHS has already shown progress in streamlining quality reporting. CMS has developed, 

in conjunction with the American Medical Association’s Consortium on Performance 

Improvement, a set of clinical quality measures for physician office-based care, which are 

now going through an expedited approval process at the National Quality Forum. The 

measures are designed in such a way as to be collected by an EHR. In addition, the IHS 

has developed specific software applications to facilitate the electronic tracking of 

patient, community, and population-based health indicators. This software is linked to 

Healthy People 2010, as well as other national quality measure sets, and can be used by 

organizations that qualify for payments in performance-based programs. The software 

application, as well as the specifications for it, are available to the public for review and 

re-use. 

Accelerate research and dissemination of evidence 

To improve human health, scientific discoveries must be translated into clinically useful 

products and applications. Such discoveries typically begin in the laboratory, where 

scientists study the mechanisms and pathogenesis of a disease at a molecular or cellular 

level, and then progress to testing in animal models and eventually people. This benchto-bedside approach is critical to ensuring a fruitful return on the public’s investment in 

research and in ensuring the safety and efficacy of future clinical therapies. It is 

important, therefore, that the federal government use information technology to 

accelerate this process. 

Information technology can be a key tool in enhancing the efficiency and effectiveness of 

the development of therapeutic agents and tools such as drugs, devices, and biologics. 

Information technology can enhance the process of organizing and conducting trials, 

including protocol development, human subject protection review, participant 

recruitment, and site selection. Information technology can also be promoted to optimize 

the safety of clinical studies, facilitating the timely reporting of safety data, as well as the 

sharing and analysis of data by the FDA, AHRQ, and the National Institutes of Health 

(NIH), and other agencies that may have oversight responsibilities. 

NIH plans to develop NECTAR, which will link research sites and ultimately create a 

“national network of networks,” in coordination with the national health information 

network, by which research information and findings will be shared and scientific 

collaborations facilitated. NECTAR includes a research workflow model, a common 

lexicon of standard vocabularies to describe medical and scientific events, and analytical 

and dissemination tools. 

26 
Framework for Strategic Action 

FDA and NIH, together with the Clinical Data Interchange Standards Consortium

(CDISC) – involving over 40 pharmaceutical companies and clinical research 

organizations – have developed a standard for representing observations made in clinical 

trials called the Study Data Tabulation Model (SDTM). This model will facilitate the 

automation of the largely paper-based clinical research process, which will lead to greater 

efficiencies in industry and government-sponsored clinical research. The first release of 

the model and associated implementation guide will be finalized prior to the July 21 

Secretarial Summit and represents an important step by government, academia, and 

industry in working together to accelerate research through the use of standards and HIT. 

The National Cancer Institute (NCI) has been piloting the Cancer Biomedical Informatics 

Grid (caBIG), and plans to implement it across 50 academic research centers supporting 

cancer research. The informatics infrastructure connects teams of cancer and biomedical 

researchers to enable them to better develop and share tools and data in an open 

environment with common standards, creating a network that links individuals and 

national and international institutions. caBIG is contributing standards-based applications 

from basic science in genomic and proteomics through those supporting clinical research 

to provide researchers with state-of-the-art tools to accelerate the discovery and 

development process. 

In another effort to speed new research discoveries to the public, NCI and FDA are also 

working to facilitate a more cost-efficient flow of higher-quality clinical research data to 

FDA. As part of the caBIG effort, they will deploy a standards-based, electronic clinical 

research exchange to support regulatory submissions. This infrastructure will allow 

secure transmission of clinical research information among sponsors, researchers, and the 

FDA. This infrastructure is being developed through an open community process 

involving academia, government, and industry to address the opportunities of this 

technology to facilitate clinical research and the issues surrounding implementation. 

Beyond using information tools to facilitate the research process, interoperable EHRs that 

can access national clinical decision support databases would also accelerate translation 

of research into practice through ready access to the latest clinical knowledge. Real-time 

delivery of clinical information to clinicians at the point of care could improve clinical 

decisions at the time they are being made. It would also allow for clinical alerts on 

medication recalls, as some large health plans have been able to do for some time, as well 

as new therapies and screening opportunities. HHS agencies will work together in 

implementing the necessary actions to translate the evidence base into practice. 

Implementation 

This Framework for Strategic Action (Framework) defines the four broad goals that will 

give rise to consumer-centric and information-rich care. It also specifies the 12 strategies 

that will be followed to accomplish these goals. The goals and strategies in the 

Framework outline a general approach to how the President’s vision for high-quality and 

efficient care will be realized. The National Coordinator will work with federal agencies 

27 
Framework for Strategic Action 

and the private sector to develop a full strategic plan and also to take actions that build

upon current progress toward the vision. 

Executive Order 13335 directed the National Coordinator to develop, maintain, and direct 

the implementation of a strategic plan to guide the nation’s implementation of 

interoperable HIT in both the public and private health care sectors. As directed by the 

Executive Order, this plan will: 

− Advance the development, adoption, and implementation of health care 

information technology standards nationally through collaboration among public 

and private interests, and ensure that these standards are consistent with current 

efforts to set HIT standards for use by the federal government; 

− Ensure that key technical, scientific, economic, and other issues affecting the 

public and private adoption of HIT are addressed; 

− Evaluate evidence on the benefits and costs of interoperable HIT and assess to 

whom these benefits and costs accrue; 

− Address privacy and security issues related to interoperable HIT and recommend 

methods to ensure appropriate authorization, authentication, and encryption of 

data for transmission over the Internet; 

− Not assume or rely upon additional federal resources or spending to accomplish 

adoption of interoperable HIT; and 

− Include measurable outcome goals. 

The Framework and related actions will follow three phases of implementation. Phase 

one will focus on the development of market institutions. Many of the agents and entities 

that are necessary for the health care industry to realize better value do not exist and must 

be developed and made operational before widespread change can occur. Certification 

organizations, group purchasing entities, and low-cost implementation support 

organizations are examples of market institutions that do not exist at this time, but which 

are necessary to support clinicians as they procure and use information technology. 

Likewise, although there are a variety of regional health information organizations, there 

is no consistent institution that can provide a platform through which financial 

investment or other support can be channeled to clinicians. 

Market institutions will stabilize the market and thereby create a better environment for 

investment and accountability. They will lower the risk of HIT procurement, thereby 

enhancing demand and making more efficient use of resources that are invested. They 

will enhance the depth and confidence of HIT buyers and will accelerate the introduction 

of quality and efficiency into the mainstream of care delivery. Through these institutions, 

lasting and positive change in the way care is delivered will be made, and subsequent 

phases will be readied. 

Phase two will involve investment in clinical management tools and capabilities. Once 

market institutions are in place, substantial investments can be made in the deployment of 

EHRs, PHRs, telemedicine, health information exchange, and other mechanisms for highperformance care delivery. Along with this, the development of the interoperability tools 

that are required to exchange health information in a secure and useful manner can 

28 
Framework for Strategic Action 

proceed. This infrastructure will result in the capacity for most physician offices, 

hospitals, and other settings to improve care provided to patients, to share information 

across settings, to incorporate new knowledge, and to allow unobtrusive monitoring and 

reporting. This will require large capital investments in technology, business process 

reengineering, and professional development. These investments will be made less risky 

and more effective by the experiences and practices of the market institutions deployed in 

phase one. They will enable the industry to manage according to principles of 

accountability and to systematically produce the quality and service in health care that is 

expected by Americans. 

Phase three will transition the market to robust quality and performance accountability. 

In this phase, clinicians will have the tools and capabilities to manage patients and 

populations, and to deliver consistently high-quality care in an efficient manner. These 

capabilities will give clinicians the means for constant improvement in practice. 

Clinicians can then be subjected to stringent quality and clinical performance monitoring, 

linked to public reporting and reimbursement, without concern about being unable to 

perform under such scrutiny or expectations. Through performance accountability, the 

priorities of clinicians can become aligned with society’s expectations for care. 

Public-Private Leadership 

Low adoption and use of HIT are attributable to many factors, including a challenging 

marketplace and a previous lack of cohesive federal policies supporting it. Leaders across 

the public and private sector recognize that the adoption and effective use of HIT require 

a joint effort between federal, state, and local government and the private sector. 

The private sector role 

While the federal government plays an important role in HIT adoption, the effective use 

of, and value creation from, this technology lies predominantly with the private sector. 

The federal government will provide a vision and a strategic direction for a national 

interoperable health care system, but will rely on a competitive technology industry, 

privately operated support services, and shared investments in HIT adoption. The private 

sector must develop the market institutions to deliver the products and services that can 

transform the paper-based health care system into an electronic, consumer-centered, and 

quality-based system. The private sector can best ensure that HIT products are 

successfully implemented in ways that meet the varying needs of American health care 

across settings, cultures, and geographies. The private sector can also continue constant 

innovation in HIT and ensure that products are delivered on an affordable basis. 

Federal and state governments have delegated most components of quality assurance to 

voluntary private organizations, including but not limited, to the JCAHO, NCQA, the 

National Quality Forum, residency review committees, and others. This will be true of

quality and performance accountability in the future world of HIT. New market 

institutions need to be developed that can support clinician adoption of HIT, provide 

interoperability, and enhance the value realized by these investments. Close 

29 
Framework for Strategic Action 

collaboration between public and private sectors can develop new methods for improving 

care without creating unnecessary regulation and minimizing reporting burdens on 

private industry. 

The federal role 

The federal government has substantial cause for addressing HIT adoption. Although the 

public is only now becoming aware of errors and mistreatments in care delivery, the 

incidence and severity of errors has been known by researchers for some time. The 

health status of Americans is lower than it would be if care were seamless, timely, and 

evidence driven. Health care inefficiency and quality problems create economic burdens 

on other industries. When working Americans spend large shares of their time moving 

between physicians, dealing with the morbidity of improperly treated chronic illness, 

handling care burdens for their elderly parents, and recovering from errors and 

unnecessary therapies, the productivity of the American labor force, and America’s 

position as a global output leader, is harmed. 

The federal government has numerous means of stimulating change in the health care 

industry, even if most of that change occurs in the private sector. While the federal 

government should not seek to reform health care without industry collaboration through 

the use of information technology, neither should it let the status quo exist simply 

because change will be difficult, complicated, and challenging to the industry. The DoD 

and VA are major federal health care delivery organizations and, increasingly, 

contractors for care in communities across the United States. The lessons these 

organizations have learned about HIT are an invaluable national asset and should be 

diffused through relationships with private delivery networks. Also, the Federal 

Employees Health Benefits Program (FEHB) contracts for care in most urban markets 

across the United States, and can drive positive economic change in general care 

delivery. Beyond finance and contracting, the current operation of the health care 

industry results from a vast patchwork of federal regulations that create many unintended 

inhibitory consequences for quality and efficiency. 

Role of the National Coordinator 

Executive Order 13335 directed the appointment of the National Coordinator for Health 

Information Technology to coordinate programs and policies regarding HIT across the 

federal government. The National Coordinator was charged with directing HIT programs 

within HHS and coordinating them with those of other relevant Executive Branch 

agencies. In fulfillment of this, the National Coordinator has taken responsibility for the 

National Health Information Infrastructure Initiative (NHII), the Federal Health 

Architecture (FHA), and the Consolidated Health Informatics Initiative (CHI), and is 

currently assessing other health information technology programs and efforts. In 

addition, the National Coordinator was charged with coordinating outreach and 

consultation between the federal government and the private sector. As part of this, the 

National Coordinator was directed to coordinate with the National Committee on Vital 

Health Statistics (NCVHS) and other advisory committees. 

30 
Framework for Strategic Action 

The National Coordinator will collaborate with DoD, VA, and OPM to encourage the 

widespread adoption of HIT throughout the health care system. To do this, the National 

Coordinator will gather and disseminate the lessons learned from both DoD and VA in 

successfully incorporating HIT into the delivery of health care, and facilitate the 

development and transfer of knowledge and technology to the private sector. OPM, as the 

purchaser of health care for the federal government, has a unique role and the ability to 

encourage the use of EHRs through the Federal Employees Health Benefits Program, and 

the National Coordinator will assist in gaining the complementary alignment of OPM 

policies with those of the private sector. 

Preliminary discussions indicate that the National Coordinator will fulfill its charge by 

performing six functions, as detailed below. 

Provide leadership 

The unified vision and strategic goals established by the President will be achieved by the 

development of common approaches to HIT. To do this, the National Coordinator will 

work with agencies to develop strategies and metrics for monitoring progress to ensure 

that it is consistent with agency mission. As the National Coordinator works with 

programs and policies across the government, gaps will be identified, along with 

solutions to fill these gaps. The National Coordinator will ensure that the federal 

government plays a key role in leveraging federal resources to encourage the private 

sector to develop a strong health information infrastructure that will serve to improve 

health care delivery and public health functions. 

Promote collaboration 

Better collaboration would benefit HIT programs across the federal government. Sharing 

information and expertise will facilitate the development and implementation of HIT 

programs and allow agencies and stakeholders to benefit from lessons learned by others. 

To improve the strength and coherence of programs across federal departments and 

agencies, the National Coordinator will develop the mechanisms to reduce redundancy, to 

fill programmatic voids, to align programs with available resources, and to maximize the 

value of the programs to the end goals of health care delivery. 

Develop policy 

The National Coordinator, working through various agencies, will develop the many new 

policies needed to implement the strategic plan. It will bring together various work 

groups that will allow for an interdisciplinary approach to policy development. 

Coordinated policies will be based on common principles and objectives across agencies. 

The National Coordinator will also integrate private stakeholder perspectives in the 

policy development process through close collaboration with the private sector. 

31 
Framework for Strategic Action 

Support financial management 

The National Coordinator will coordinate investments in HIT by maintaining a strategic 

plan that can be used as a guide and reference for prioritization in the budget process. 

The National Coordinator will work with agencies and departments to ensure that budget 

requests for HIT are coordinated so that federal investments are unified, cost-effective, 

and aligned with overall federal strategy. 

Enhance communication and outreach 

Ongoing communication between public and private decision makers will be critical to 

success of the strategic plan. The National Coordinator will work with federal agencies

to transfer useful knowledge to the private sector where appropriate, and will ensure that 

public and private HIT efforts share information to the degree possible. Also, the 

National Coordinator will work with NCVHS and other federal advisory bodies to ensure 

that private sector input is systematically incorporated into policies and programs, where 

applicable. 

Evaluate effectiveness 

The National Coordinator will work with agencies to assess the effectiveness of HIT 

policies and programs. To do this, the National Coordinator will work with federal 

agencies to develop metrics that can assess progress toward strategic goals over time and 

across programs. Also, the National Coordinator will identify model business processes 

that can support collaboration and harmonization of federal HIT programs. The National 

Coordinator will also work with federal agencies to compare ongoing HIT programs to 

reference architectures, business requirements, and data standards so that variations and 

gaps can be assessed and addressed as possible within agency mission. 

Conclusion

Health information technology provides a mechanism for refocusing care delivery 

around consumers without substantial regulation and industry upheaval. Information 

technology can result in better care (care that is higher in quality, safer, and more 

consumer responsive) and at the same time, more efficient (care that is appropriate, 

available, and less wasteful). There are very few other alternatives that can achieve both 

of these goals in a balanced and timely manner. 

A national strategy for HIT is needed to achieve this change. This strategy should inform

clinical care by introducing EHRs on a widespread basis everywhere clinicians provide 

treatment. It should interconnect clinicians to allow them to share data in a seamless and 

secure manner that protects patient privacy. It should customize health information and 

care so that consumers can have more control, more treatment options, and more choice 

of providers, including clinicians who may be at a distance. It also should improve 

population health by monitoring health care delivery in a simple and timely fashion so 

that quality, public health risks, and clinical research can be enhanced. 

32 
Framework for Strategic Action 

The changes that will accompany the application of information technology to health care 

will be difficult and will challenge fundamental assumptions that have been long held. 

However, this change is inevitable, needed, and beneficial. Actions can and should be 

taken to ensure that this change happens sooner rather than later, is more widespread 

rather than less, and also improves health care quality while addressing health care costs. 

The actions that are taken over the next decade will ensure that the best health care can be 

delivered to Americans, and that lasting and positive change in the health care industry 

will result. 

33 
Framework for Strategic Action 

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36 
Framework for Strategic Action 

Glossary of Selected Terms

Computerized Provider Order Entry (CPOE) – A computer application that allows a 

physician’s orders for diagnostic and treatment services (such as medications, laboratory, 

and other tests) to be entered electronically instead of being recorded on order sheets or 

prescription pads. The computer compares the order against standards for dosing, checks 

for allergies or interactions with other medications, and warns the physician about 

potential problems. 

Consolidated Health Informatics (CHI) Initiative – One of the 24 Presidential 

eGovernment initiatives with the goal of adopting vocabulary and messaging standards to 

facilitate communication of clinical information across the federal health enterprise. CHI 

now falls under FHA. 

Decision-Support System (DSS) - Computer tools or applications to assist physicians in 

clinical decisions by providing evidence-based knowledge in the context of patientspecific data. Examples include drug interaction alerts at the time medication is 

prescribed and reminders for specific guideline-based interventions during the care of 

patients with chronic disease. Information should be presented in a patient-centric view 

of individual care and also in a population or aggregate view to support population 

management and quality improvement.

Electronic Health Record (EHR) – A real-time patient health record with access to 

evidence-based decision support tools that can be used to aid clinicians in decisionmaking. The EHR can automate and streamline a clinician's workflow, ensuring that all 

clinical information is communicated. It can also prevent delays in response that result in 

gaps in care. The EHR can also support the collection of data for uses other than clinical 

care, such as billing, quality management, outcome reporting, and public health disease 

surveillance and reporting. 

Electronic Prescribing (eRx) – A type of computer technology whereby physicians use 

handheld or personal computer devices to review drug and formulary coverage and to 

transmit prescriptions to a printer or to a local pharmacy. E-prescribing software can be 

integrated into existing clinical information systems to allow physician access to patientspecific information to screen for drug interactions and allergies. 

Enterprise Architecture – A strategic resource that aligns business and technology, 

leverages shared assets, builds internal and external partnerships, and optimizes the value 

of information technology services. 

Federal Health Architecture (FHA) – A collaborative body composed of several 

federal departments and agencies, including the Department of Health and Human 

Services (HHS), the Department of Homeland Security (DHS), the Department of 

Veterans Affairs (VA), the Environmental Protection Agency (EPA), the United States 

Department of Agriculture (USDA), the Department of Defense (DoD), and the 

37 
Framework for Strategic Action 

Department of Energy (DOE). FHA provides a framework for linking health business 

processes to technology solutions and standards, and for demonstrating how these 

solutions achieve improved health performance outcomes. 

Health Information Technology (HIT) – The application of information processing 

involving both computer hardware and software that deals with the storage, retrieval, 

sharing, and use of health care information, data, and knowledge for communication and 

decision making. 

Personal Health Record (PHR) – An electronic application through which individuals 

can maintain and manage their health information (and that of others for whom they are 

authorized) in a private, secure, and confidential environment. 

38 
ATTACHMENT 1: 

Report from the Office of Personnel Management 

INTEROPERABLE HEALTH

INFORMATION TECHNOLOGY

REPORT TO THE PRESIDENT

TATES OFF'!

,James, Dhi'!

UNITED STATES

OFFICE OF PERSONNEL MANAGEMENT

WASmNGTON, DC 20415-1000

OFFICE OF mE DIRECTOR

Dear Mr. President:

On April 27, 2004, you issued Executive Order 13335, Incentives for the Use of Health

Information Technology and Establishing the Position of the National Health Information

Technology Coordinator. This order establishes the importance you place on the development

and implementation of a nationwide interoperable health information technology (HIT)

infrastructure to improve the quality and efficiency of health care.

The Executive Order embodies your vision to develop a nationwide interoperable health

information technology infrastructure that:

a) Ensures appropriate information to guide medical decisions is available at the time

and place of care;

b) Improves health care quality, reduces medical errors, and advances the delivery of

appropriate, evidence-based medical care;

c) Reduces health care costs resulting from inefficiency, medical errors, inappropriate

care, and incomplete information;

d) Promotes a more effective marketplace, greater competition, and increased choice

through the wider availability of accurate information on health care costs, quality,

and outcomes;

e) Improves 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,

f) Ensures that patients' individually identifiable health information is secure and

protected.

In order to help fulfill your vision, you directed me to submit a report within 90 days

of your order on options to provide incentives in the Federal Employees Health

Benefits (FEHB) Program to promote the adoption of interoperable health

information technology. I am pleased to submit this report to support this

important undertaking.

Sincerely,

~~~~- - KayColesja~

Director

CON 131-64-4

September 2001

Interoperable Health

Information Technology

A Report for:

The Honorable George W. Bush

President

United States of America

on

Federal Employees Health Benefits Program

Initiatives to Promote the Use of Health

Information Technology

by

Kay Coles James

Director

U.S Office of Personnel Management
INTRODUCTION

OVERVIEW

The Federal Employees Health Benefits (FEHB)Program began in 1960. It is the largest

employer-sponsored group health insurance program in the world, covering more than 8

million Federal employees, retirees, former employees, family members, and former

spouses.

Public Law 86-382, enacted September 28, 1959, created the FEHB Program. The law

governing the Program is chapter 89 of title 5, United States Code. The law authorized

the Civil Service Commission (now the Office of Personnel Management OPM) to write

regulations necessary to carry out the Act. These regulations are in part 890 of title 5 and

chapter 16 of title 48, Code of Federal Regulations.

Over 200 health plan choices currently are offered under the FEHB Program. There are

twelve fee-for-serviceplans, of which seven are open to all enrollees, while the rest are

available only to specific categories of employees. In addition, health maintenance

organizations (managed care plans) are available in many specific local areasthroughout

the United States. Premiums and benefits are negotiated annually. Premiums and

benefits vary among the plan offerings allowing Federal employees and retirees a wide

choice to suit their individual circumstances.
This consumer-based choice is a key hallmark of the FEHB Program. The Government

pays on average about 72% of the cost of the health benefits coverage, and enrollees pay

the remainder, based on a formula set by law.

The FEHB law provides OPM wide authority to contract with various private health

insurance plans. Annual contract negotiations are a bilateral process, and both OPM and

the plan must agree on the final terms. Individual policies or contracts are not issued to

FEHB Program enrollees. Each enrollee is given a detailed description of benefits so the

consumer may use the open enrollment period to choose the best protection for his or her

circumstances.

NEGOTIATIONS

The negotiation process in the FEHB Program formally beginsin the spring of each year.

OPM sends all current and newly approved qualified health plans the annual Call Letter

to advise them on goals and proceduresfor negotiation of contractsthat will be effective

the following January. In conjunction with the Call Letter, OPM issues instructions for

premium rate negotiation for the upcoming contract year. There are two rating types,

experience rating and community rating. All proposals are due by May 31.

The Office of the Inspector General audits health plans to make sure our costs are

appropriate.
PREMIUM RATE NEGOTIATIONS

Experience Rating

Experience rating bases the FEHB Program premiums on its benefit costs and

administrative expenses. OPM's actuaries also evaluate each plan's rate proposal in

relation to past premiums and anticipated future premium requirements to ensure the

plan's premiums will be reasonably stable, represent good value for the benefits provided,

and remain competitive with other FEHBplans. Fee-for-service plans and some HMOs

are experience rated. The goal of the experience-ratenegotiation is to make sure

premiums are set high enough to support the plan's expenses but low enough to be

competitive. Rate negotiationsreflect a dynamic between premiums and costs and

covered expenses. aPM rate instructionsfor experience rated plans are detailed and

feature protection for the Government, enrollees, and plans. Funds in excess of a plan's

current needs are held in the Employees Health Benefits Fund in the U.S. Treasury. The

reserves provide a protective cushion against unanticipated costs and help achieve rate

stability.

Each year specific profit margins are negotiated. This is the only profit allowed for

experience rated plans. If at the end of a contract period there are excess funds over

expenses, the excesses are credited to the reserve, not kept by the plan.
Community Rating

The majority of FEHB plans are health maintenance organizations(HMOs) and use

community rating. This rate-setting methodologyis based on what the plan chargesits

other groups. OPM analyzes and reviews each plan's rate to ensure the FEHB rates are

fair. Our community rates are based on the best ratesthe plan offersits two subscriber

groups most similar to the FEHB group. Preferentialrates granted to a group similar to

the FEHB group must be granted to the Government.

Like experience-rated plans, the FEHB maintainsreserves to mitigate rate instability,rate

increases, and benefit changes.
SUPPORT FOR INTEROPERABLE HEALTH INFORMATION IS GROWING

Below are brief summaries of typical initiatives related to interoperable health

information technology that are currently emerging.

WellPoint, a Blue Cross and Blue Shield local plan, recently began a program called

Prescription ImprovementPackage. The program offers physicians, at no charge, a

wireless, handheld electronic prescribing unit, a wireless access point, and a one-year

subscription to an e-prescribing service.Initially,WellPoint will target 2,000 physicians

who can support the technology. The WellPoint effort is aimed at reducing medication

errors and saving costs by decreasing duplication of services. This allows physiciansto

discard their prescription pads in favor of electronic transmissions to any pharmacy.

Well Point, with Microsoft's Healthcare and Life Sciences Group acting as technology

consultant, provides Microsoft e-prescribing software to the 19,000 physicians in

WellPoint's network in California, Georgia, Missouri, and Wisconsin.

Empire Blue Cross and Blue Shield is in the last stages of a program that awards bonus

payments to hospitals that meet certain Leapfrog standards. Payments are paid by

participating employers and equal a percentage of the hospital claims for employees of

the participating employers. The self-funded employers are ffiM, Verizon

Communications, PepsiCo, and the Xerox Corporation. The goal of this program is to

reduce errors and improve health care quality through the increased use of Computer

Physician Order Entry (CPOE) and other LeapfrogGroup standards; reward technical
innovation; and raise the standardsfor all hospitals in health information technology HIT

adoption and health outcomes. A formal evaluation to assess the impact on

improvements in quality of care and error avoidance is planned when the program

concludes.

Blue Cross & Blue Shield of Massachusetts will start paying primary care physicians at

Beth Israel Deaconess Medical Center,Caritas Christi Health Care, and Baystate Health

System for "Web visits" with their patients beginning August, 2004. Harvard Vanguard

Medical Associates, the large Eastern Massachusetts doctors' group, and the insurer

Harvard Pilgrim Health Care, also are experimentingwith doctor-patiente-mail

programs. At Beth Israel Deaconess, patients can enroll in "PatientSite,"an online system

that allows them to schedule appointments, look up test results, and e-mail their doctors.

Blue Cross only is paying doctors who use a standardized Web visit form developed to

provide secure online communication.

Anthem Blue Cross and Blue Shield provides a member Website that provides

members with an individually tailored online experience that offers quicker, easier, and

more efficient access to self-service tools and member-specific health information.

Members use the Website for four reasons: to view their membership information, to

choose or change health care providers, to learn about health and wellness, and to shop

for health-related products and services at discounted prices. Memberslog in and then
have one-click accessto MyServices,MyProviders,MyHealth, and MySpecialOffers- all

efficiently organized by tabs and links - for easy navigation.

MyAnthem offers members the opportunity to become more involved in their health care

through online capabilities that allow greater clarity, simplicity, and management over

their health care benefits. MyAnthem provides an easy way to help members gain more

control over their health care benefitsthrough secure access that's available at any time

and from any place. The new Website satisfies many member needs in that it offers a

personalized experience, customized content, simplified user interface and improved

communication, and enhanced relationshipsthat can translate into more information and

tools at the member level allowing the member to make informed decisions about his or

her health care.

Integrated Healthcare Association (iliA) has convened six large California health plans

in a pay-for-performanceprogram. The health plans award bonuses to physician groups

based on an aggregate score that includes clinical measures, patient satisfaction, and IT

investment. While each health plan sets its own dollar award, iliA suggests a bonus

amount of 5-10% of the per-member capitation payment. The IT portion of the bonus is

based on the physician groups' abilityto match multiple clinical data sets at the patient

level and to deliver electronic data at the point of care (electronic health records,

electronic lab results, patient registries, etc.).
Bridges to Excellence (BTE), a Robert Wood Johnson-sponsoredinitiative, is focused on

creating system-wide improvements in care deliveryby linking physician payment and

performance. This initiative, which includes a consortiumof quality partners, health

plans, and providers has two current projects underway - Physician Office Link (POL)

and Diabetes Care Link (DCL). POL stressesthe necessity and value of an HIT

infrastructure in a physician's office to promote error reduction and quality

improvements. Rewards are based on a physician's use of clinical information systems

and evidence-based medicine; patient education and support; and care management. The

intent is to establish a HIT infrastructure and link it to improvementsin the providing of

more efficient and higher quality care. The DCL's intent is to test the effectiveness and

impact of the HIT infrastructure by using HEDISmeasures for patients undergoing

treatment of diabetes. These proven measures will help the program assess the success of

the POL.

MVP and Taconic IPA (TIPA) have developed a partnership,MedAllies, to provide

technical assistance, IT support, and other related services. The objective is to develop a

community-orientedmodel through progressive improvementsin the continuity of care

and connectivity across all providers in the TIPA. Through a phased implementation of

an electronic health record EHR, the ultimate goal is to have a highly integrated

community data exchange to include physicians,labs, and hospitals. There is no planned,

formal, quantitative evaluation, with success being measured by the level of participation.

Participation is high and growing to include local community hospitals. MedAllies has
discontinued paymentfor most of the technology upgradesin physician offices because

TIPA and MVP expect financial incentive bonuses to offset the costs for

hardware/softwareupgrades.

Health and Human Services, Centers for Medicare and Medicaid Services (CMS), is

in the process of implementing a three-yeardemonstration project, the Doctor Office

Quality-InformationTechnology (DOQ-IT) project. Medicare Advantage plans will be

providing financial incentivesto physician offices to adopt HIT and meet certain

performance measures. Physiciansmust treat a certain number of Medicare beneficiaries

and meet specific systems and processrequirementsthat include adoption of IT and care

management. The physicians also must agree to phase in, over the three-yeartimeframe,

the use of HIT to manage clinical care and electronic reporting of clinical quality and

outcomes measures data. Several goals of this project are to adopt HIT in small- to

medium-sized physician offices to promote continuity of care and stabilization of medical

conditions, and to reduce adverse health outcomes of those beneficiaries with chronic

illnesses.

CMS currently is conducting a Medicare demonstration project that uses financial

incentives to encourage hospitals to provide high quality inpatient care. Hospitals that

deliver the best quality of care will be rewarded with higher Medicare payments.

Bonuses will be awarded based on a hospital's performance on evidence-based quality

measures for a variety of medical conditions. Only top performing hospitals will receive
monetary bonuses. While there is not a specificHITcomponent, information on each

hospital's performance will be made available to health care providers and consumers

that will contribute to a wider availability of information and informed choice.
WHAT OPM IS DOING NOW

aPM recognizes that in order to achieve shared goals and broaden the health care

spectrum, there must be a collaborative effort from all organizationsinvolved in the

process. As the largest purchaser of employee health care benefits, aPM has undertaken

and affiliated itself with a variety of organizationsworking toward common goals such as

quality and affordable health care, positive medical outcomes, reduction of medical

errors, wider availability of health information, and the creation of a competitive

marketplace that provides choice to the consumer.

OPM's COLLABORATIVE EFFORTS TO SUPPORT HIT

National Quality Forum (NQF)

NQF is a membership organization that is developing and implementing a national

strategy for health care qualitymeasurement and reporting. aPM currently serves as the

Quality InteragencyCoordination Task Force (QuIC)representative to NQF's Board of

Directors.

Quality Interagency Coordination Task Force (QuIC)

The QuIC is an interagency task force charged with ensuring all Federal agencies

involved in purchasing, providing,studying, or regulating health care services are

coordinating their work on improving health care quality. aPM chairs the Patient and
Consumer InformationWorkgroup, one of five workgroups carrying out the QuIC's

mISSIon.

Leapfrog Group (LFG)

Sponsored by the Business Roundtable, the LFG's goal is to mobilize employer

purchasing power to initiate breakthrough improvementsin the safety and overall value

of health care to American consumers. aPM participates as an LFG liaison member of

the Board.

National Committee on Quality Assurance (NCQA)

NCQA's mission is to improve the quality of health care delivered to people everywhere.

NCQA is active in quality oversight and improvement initiatives at all levels of the health

care system. NCQA is best known for its activity of assessing and reporting on the

quality of the nation's managed care plans through its accreditation and performance

measures program. NCQA currently is supporting HIT by its new standards that

support the Bridges to Excellence. aPM has a long standing association with NCQA.

National Business Group on Health

Formerly the Washington Business Group on Health, representing over 200 large

employers, health care companies, benefits' consultants, and vendors, it is the nation's

only nonprofit organization devoted exclusively to finding innovative and forwardthinking solutions to the nation's most important health care and related benefits issues.
Joint CommissionBusiness Advisory Group

Created by the Joint Commission on Accreditation of Healthcare Organizations

(JCAHO), the Business Advisory Group provides counsel on employer prioritiesin the

evaluation of health care quality and assists the Joint Commission in identifying quality

and safety issues important to employers. OPM is a member of the Board. The group

meets several times each year and includes a cross section of individuals and coalitions

representing businesses of varying sizes and different types of purchasing arrangements

across the country. The Joint Commission relies on a variety of advisory groups in its

continuous effort to improve the safety and quality of care provided to the public. These

groups provide feedback to help JCAHO develop and revise standards, policies, and

procedures that support performance improvement in health care organizations.

Center for Health Transformation

OPM has become actively engaged with the Center for Health Transformation through

discussion and attendance at conferencessponsored by the Center. The Center for Health

Transformation's vision is to accelerate the transformation of health and health care into a

dynamic 21st century intelligent health systemthat results in better health, more choices,

and lower costs to all. We share the Center's idea that the key drivers to health

transformation are:

. patient safety and patient outcomes;
. information and communication technology;

. a system and culture of quality; and,

. individual knowledge, responsibility and power to choose.

eHealth Initiative

OPM hasjust been invitedto join the Employer and PurchaserAdvisory Board of the

, eHealth Initiative. The eHealth Initiative is moving forward aggressively to create

national and local collaborative efforts~witliceI11ployers t6 support a common goal of

higher quality, safer and more .efficienthealthcare enabled by information technology.

The eHealth Initiative supports the improvement of measurement ability, data integrity, . .

and efficiency of collection and transmission of data.

I'

The Employer and Purchaser Advisory Board of the eHealth Initiative and its Foundation

is a vehicle for high-level discussions of issues important to the employer community and

members of the eHealth Initiative. The group was formed to support the further

development of the eHealth Initiative's strategy and the successful execution of its

mission, which is to improve the quality,safety and efficiency of healthcare through

information and information technology.

~

"
Below are summaries of OPM's initiatives alreadyunderway that can help

leverage its purchasing power to support HIT.

Pharmacy Benefit Management Arrangements

Many FEHB plans have had contractual arrangementswith pharmacy benefit managers

(PBMs). Prescription drug costs represent a high percentage of total FEHB costs. PBMs

provide real time online accessto member enrollmentrecordsto facilitate point-of-sale

transactions. This technology can be leveraged to promote patient safety and

connectivity. The interconnectivitythat PBMs have with retail pharmacies can serve a

vital role to link providers and pharmacies.

Care Management

FEHB plans generally provide care managementservicesfor members with chronic

conditions, including flexible benefit options and diagnosis-based programs. Care

management programs help educate affected members about their chronic conditions

and help ensure they are getting appropriate services. It is generallyaccepted that a

relatively small percentage of members, primarilythose with chronic conditions, use

the greatest percentage of benefits. By addressing the needs of this chronically ill

population, health plans help improve the quality of care and promote the effective use

of benefit dollars. Online decision support tools available to members help facilitate

their access to information and educational materials.
Further, aPM has asked plans to begin the process of establishing a link between their

care management programs and Long Term Care Partners, the administrators of the

Federal Long Term Care msurance Program (FLTCIP),so enrollees with FLTCIP

coverage can experience a smooth transition to long term care when necessary.

HealthierFeds

aPM's HealthierFeds campaign places emphasis on educating Federal employees and

retirees on healthy living and best-treatment strategiesto reduce demand on the health

care system. This OPM initiative is featured at www.healthierfeds.govon OPM's Web

site. It supports the President's HealthierUS initiative which follows a simple formula:

every little bit of effort counts. The Administration's initiative has identified four keys

for a healthier America: be physically active every day, follow a nutritious diet, get

preventive screenings, and make healthy choices. aPM has reinforced with FEHB plans

that educating their members may lead to more patient involvement in health care

decision making and, subsequently,more consumer responsibility.

Quality Initiatives

Quality is a very important aspect of managing health care programs. Quality is how well

health plans keep their members healthy, or treat them when they are sick. Good quality

doesn't alwaysmean receiving more care. Good quality health care means doing the right

thing at the right time, in the right way, for the right person, to achieve the best possible

results.
OPM is continuing to provide FEHB members with resources that will help them choose

high-quality health plans. OPM provides FEHB members with the accreditation status of

participating health plans in our annual Guide to FEHB Plans. Accreditation

demonstrates an organization's commitment to providing quality, cost-effective health

care. Providing FEHB members with accreditation information allows consumers to

choose a high quality health plan.

OPM also provides Federal employees and retirees with individual health plan ratings

based on the results of our annual Consumers' Assessment of Health Plans Survey. This

consumer survey allows current plan membersto rate their health plans and providers in

several key areas, including overall satisfaction,satisfactionwith their providers, access

to care, customer service, and claims processing. Providing FEHB members with this

consumer survey information allowsthem to consider the feedback of other consumers

when choosing a health plan.

E- Initiatives

OPM is continuing to expand the use of the Internet as a valuable communications and

resource tool. During the annual open season events, OPM provides in various ways,

comprehensive program information, including health plan brochures, FEHB guides,

premiums and other useful information our customers need to choose a quality health

plan. The FEHB Website, linked from the OPM website, www.opm.gov.links to a report
card designed by the National Committee for Quality Assurance (NCQA). This report

card helps users learn more about the quality of care and service provided by HMOs.

FEHB consumers also have accessto an OPM health plan comparison tool. Most plan

consumer information can be linked through OPM's portal.

Patient Safety

During the past few years, the health care community has stressed the importance of a

culture of patient safety. Weare continuing our work with FEHB plans adding

information on their patient safety initiatives and programsto the FEHB Website.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA), subtitle,

Administrative Simplification, requires the Secretary of Health and Human Services

(HHS) to adopt standards for: ten electronic administrative and financial health care

transactions; unique identifiers for individuals, employers, health plans, and health care

providers; protecting the privacy of individually identifiable health information; and

providing security for individually identifiable health information and electronic

signatures. HHS has now published several final HIPAA regulations. The compliance

deadline for electronic transactions was October 2003. OPM successfullymigrated from

its proprietary enrollment transaction format to the HIPAA standard format. The final

HIPAA privacy regulations were effective April 2003. The security regulations will

become effective April 2005 for most plans and April 2006 for small plans. The
national provider identifier regulations will become effectiveMay 2007 for most plans

and May 2008 for small plans. All OPM contractsrequire HIPAA compliance. OPM is

working closely with FEHBplans to ensure a smooth transition in meeting these

important requirements.

PROVISIONS AVAILABLE TO OPM TO PROVIDEINCENTIVES

OPM purchases health benefits coverage for over 8 million employees, annuitants, and

dependents. OPM's significant purchasing power is powerful leverage to contract for a

comprehensive set of health benefits at affordable prices. Through this leverage, OPM

continues to capitalize on the great efficiencies and economies that can be achieved.

OPM fully supports initiatives to further an effective and competitive marketplace as it

explores ways to adopt HIT in the FEHB Program that will bring knowledge-based tools

to the hands that deliver health care.

The end result of any such program is to raise the bar so that everyone is performing at a

higher level. It should be a program that fosters an environment of winners, not winners

and losers. In this era of budget consciousness,investment and return on investment are

pivotal to purchasers and providers. Therefore, to use purchasing leverage to gain a

meaningful and lasting move toward the adoption and full implementation of HIT, OPM

needs to move forward in a way that is shared by all stakeholder groups. Incentives
should be properly aligned and meaningful to ensure that both costs and returns are

shared by all.

As aPM exerts its purchasing power, it will support the adoption of common standards of

performance, outcome, and incentives. The use of accepted standards developed by

recognized quality and accreditation organizations lendsitself to greater leverage and

earlier adoption. aPM will leverage its purchasing power to move forward, not to

reinvent the wheel.

aPM's goals in the marketplace will be to:

. Reduce health care costs by increasing efficiency and reducing medical

errors, inappropriate care and incomplete care;

. Improve health care quality;

. Ensure appropriate information is available to guide medical decisions

at the time and place of care;

. Improve care coordination; and

. Partner with aNCHIT and collaborate with Federal partners and other

public and private stakeholders.

Incentives may be provided several waysin the FEHB Program. aPM can explore

regulatory changesto help encourage profit incentives for plans to foster HIT adoption

and implementation. Experience-rated plans can be rewarded for progresstoward
adopting or adapting incentivesfor HIT. Using plans' profit motive should help aPM

leverage its market position to help HIT adoption.

Community rated plans incorporate both their administrative expenses and any profit

amount into their rates. Community rated plans are subject to performance goals and

incentives. aPM can explore regulatory changesto align current plan performance

elements to include HIT adoption.

OPTIONS

aPM will explore adoption of a variety of options, such as those below, to speed the

nationwide phase-in adoption of HIT as soon as practicable.

1) Strongly encourage FEHB Program participating health plans to adopt systems

that are based on the Federal Health Architecture standards.

2) Strongly encourage health plans to highlight their provider directories to indicate

individual provider HIT capabilities.

3) Strongly encourage health plans to link disease management and quality initiatives

to HIT systemsfor measurable improvements.
4) Strongly encourage health plans to provide incentivesfor the adoption of

interoperable health infonnation technology systemsby key providers under

FEHB contracts.

5) Base part of the service charge, or profit, for fee-for-service and other experiencerated plans on their developing incentives for:

. Doctors and pharmaciesto use paperless systemsto fill prescriptions

(ePrescribing);

. Contracting with hospitals that use electronic registries, electronic

records, and/or ePrescribing; and

. Increasing the number of enrollees whose providers use electronic

registries, electronic records, and/or ePrescribing.

6) Introduce performance goals for HMOs (community rated plans) that are linked to

their developing incentives for:

. Doctors and phannacies to use paperless systemsto fill prescriptions

(ePrescribing);

. Contracting with hospitals that use electronic registries, electronic

records and/or ePrescribing;

. Increasing the number of enrollees whose providers use electronic

registries, electronic records and/or ePrescribing.
7) Introduce incentives and performance goals for plans that contract with networks

of providersto make records accessiblethrough secure and HIPAA compliant

interoperable HIT systems.

8) Introduce incentives and performance goals for plans that integrate their provider

networks with local and national health information infrastructure initiatives.

9) Encourage and reward pharmacy benefit managersfor providing incentivesfor

ePrescribing and health information technology linkage.

OPM has great respect for the power and creativity of the private sector to

determine solutions. We will continue to collaborate with our private sector

partners as well as our public sector partnersto achieve the goals set by President

George W. Bush in his Executive Order. We believe these goals can be achieved

without violating the key principle that desired outcomes can be achieved through

negotiation rather than imposed through mandates.


ATTACHMENT 2: 

Report from the Veterans Administration 



Department of Veterans Affairs 

Report On 

Approaches to Make Health Information Systems Available and Affordable to 

Rural and Medically Underserved Communities 

In cooperation with the 

Department of Defense 

Executive Summary ........................................................................................................ 3 

I. INTRODUCTION...................................................................................................... 5 

II. BACKGROUND—Statement Of Problem: Rural and Medically Underserved 

Requirements 

 ................................................................................................................................. 5 

III. THE VA ELECTRONIC HEALTH RECORD............................................................ 8 

IV. VA/DoD COLLABORATIVE APPROACHES TO FACILITATE THE TRANSFER 

OF AFFORDABLE HEALTH INFORMATION TECHNOLOGIES.................................. 11 

A. Knowledge Transfer of Information Exchange Lessons ...................................... 11 

Federal Health Information Exchange.............................................................. 11 

CHCS/VistA Data Sharing Interface................................................................. 12 

Clinical Data Repository/Health Data Repository Interoperability .................... 12 

Other Technologies.......................................................................................... 13 

B. Adoption of Common Standards and Terminologies .......................................... 13 

C. TeleHealth Technologies Used for Long Distance Consultations and Distance 

 Learning............................................................................................................. 16

V. OTHER VA APPROACHES – Knowledge and Technology Transfers to Benefit 

 Target Populations .............................................................................................. 17 

A. VistA For Use in Office-Based Practices and Clinics.......................................... 17 

B. My HealtheVet - The Personal Health Record.................................................... 18 

C. Bar Code Medication Administration .................................................................. 18 

D. Telehealth/Telemedicine .................................................................................... 19 

E. VistA Imaging Technology.................................................................................. 20 

F. Support of Community and Regional Setting Broad Data Exchange Initiatives.. 20 

G. Contracting Incentives With Private Providers.................................................... 20 

VI. SUMMARY AND RECOMMENDATIONS.............................................................. 21 

APPENDIX A - DEFINITIONS (Health Resources and Services Administration).......... 23 

APPENDIX B - TARGET VA/DoD STANDARDS PROFILE.......................................... 24 

APPENDIX C - VA COLLABORATIVE STANDARDS AND TERMINOLOGY EFFORTS

...................................................................................................................................... 27 

APPENDIX D - VA/DOD TELEHEALTH TECHNOLOGIES .......................................... 28 

APPENDIX E - EXAMPLES OF VA PUBLIC DOMAIN TECHNOLOGY TRANSFERS. 31 

APPENDIX F - EXAMPLES OF VA DATA EXCHANGE INITIATIVES.......................... 32 

TABLE OF ACRONYMS ............................................................................................... 33 

2
Executive Summary

By Executive Order, the President directed that the Secretaries of the Departments of 

Veterans Affairs (VA) and Defense (DoD) develop a joint approach to work with the 

private sector to make their health information systems available as an affordable option 

for providers in rural and medically underserved communities. This report is submitted 

on behalf of VA through the Secretary of the Department of Health and Human Services 

(HHS). It provides coordinated VA/DoD recommended approaches that focus on the 

capture of lessons-learned and technology and knowledge transfers from data 

exchange initiatives, the adoption of common standards and terminologies, and the 

development of telehealth technologies. 

In cooperation with HHS, and as also mandated by the President’s Executive Order, VA 

is contributing to the development of a national Strategic Plan that will address a 

coordinated strategy to improve the delivery of health care by evaluating and 

recommending technologies that are available across the Federal government. The 

task to compile the technology listing is delegated to the Office of the National 

Coordinator for Health Information Technology (ONCHIT) and recommendations from 

this report will feed into the larger Strategic Plan. 

The report summarizes the comprehensive and close collaboration that VA and DoD 

have forged to develop interoperable health technologies to improve the quality of care 

for separate and shared beneficiaries, and to better utilize government resources. As a 

result of this history, the Departments are able to make a number of recommendations 

that are identified as a result of coordinated approaches related to data exchange, 

standards, and telehealth. These approaches include private sector partnering or 

influence and would facilitate the provision of technology to rural and medically

underserved populations; therefore, all should be given consideration for inclusion into 

the overall Strategic Plan. The joint recommendations include: 

o Capture lessons learned, including technical and resource identification, of data 

sharing initiatives. Where appropriate, conduct technology transfers to private 

sector and state and local levels as a means of providing affordable technologies 

to these areas. 

o Continue joint standards adoption work to leverage the immense capability to 

influence the vendor community in the development of affordable health 

technologies. 

o Continue utilization and development of telehealth technologies to be used in the 

direct provision of care to geographically remote areas and areas that are 

underserved by health delivery services. 

o Continue development of personal health record technologies that will support 

the transformation of health care into a patient centric and patient participatory 

process. 

3
In addition to joint work conducted with DoD, VA brings immense experience and 

capabilities to this effort to leverage Federal health information technologies for the 

benefit of the rural and medically underserved. VA is a world-class leader in the use of 

electronic health record technology in the care provided to its patients. As an overall 

health information technology strategy, VA has focused on the development of 

electronic and personal health record technologies, the adoption and implementation of 

standards into technologies, participation in broad-data exchange initiatives with 

community-based and private care partners, as well as the development of 

interoperable health records. 

Much of VA’s Veterans Information Systems & Technology Architecture) (VistA) system

was developed by VA government resources and, therefore, the software exists in the 

public domain. Through on-going and active collaborations with a number of 

government and private-sector resources, VA encourages the proliferation of public 

domain technologies based on VistA code. This approach reduces expensive 

development costs associated with software and human capital requirements and 

makes proven electronic health record (EHR) technology an affordable and directtransfer option to rural and medically underserved communities. VA’s approach directly 

supports the provision of health information technology expertise to communities where 

it is needed most, at very little cost. 

VA’s successes with technologies such as VistA, HealthePeople-VistA, the 

Computerized Patient Record System (CPRS), the Bar Code Medication Administration 

System, telehealth and VistA Imaging technologies, and the My HealtheVet personal 

health record, are ripe for adoption into a national strategic plan to leverage Federal 

technologies to improve health care for all citizens. As a leading provider of Federal 

health care, and an active participant and partner with multiple national and private 

sector health information technology initiatives, VA is well-prepared to implement each 

recommendation contained in this report. 

4
I. INTRODUCTION 

On April 27, President Bush issued the Executive Order Incentives for the Use of Health 

Information Technology and Establishing the Position of the National Health Information 

Technology Coordinator. The purpose of the Order was for “the development of an 

interoperable health information technology infrastructure to improve the quality and 

efficiency of healthcare.” The Executive Order is consistent with the goal expressed by 

President Bush to ensure that the medical records of a majority of Americans are 

available in electronic format within 10 years. 

As part of this Order in Section 4(b), the President directed the Secretaries of the 

Departments of Veterans Affairs (VA) and Defense (DoD) to report on the following: 

The approaches the Departments could take to work more actively with the 

private 

sector to make their health information systems available as an affordable option 

for providers in rural and medically underserved communities. 

The Order requires the Departments to document their approach in reports within 90 

days, by July 27, 2004, and to submit the reports to the President through the Secretary 

of Health and Human Services (HHS). On behalf of the Secretary, the Office of the 

National Coordinator for Health Information Technology (ONCHIT) is responsible for 

coordination of such reports. Likewise, through ONCHIT, HHS is preparing a larger 

Strategic Plan that will address the transformation of health care delivery through 

information technology. 

This report meets the VA requirement to submit an approach through ONCHIT to make 

health information technologies available to rural and medically underserved 

communities. This report also provides VA’s contribution to the larger HHS Strategic 

Plan that will provide recommendations to transforming health care delivery using 

information technology. 

II. BACKGROUND—Statement Of Problem: Rural and Medically Underserved 

Requirements 

The Rural Public Health Research Agenda of April 2004, held at the University of 

Pittsburgh Center for Rural Health Practice, identified the following core themes for 

Rural Public Health: 

5
 

 

 

 

Rural communities differ significantly across and within geographic

regions. Such differences necessitate local solutions to local challenges 

that include economic factors, demographic makeup, population density, 

terrain, and distance from urban areas, community resources and public 

health presence. 

The vast majority of rural public health workers have no formal public 

health training. An additional barrier to needed education and training is 

the inability to take time away from often understaffed local health 

departments. 

There is a need for surveillance systems to be sensitive enough to 

address small number issues and broad enough to track emerging 

infections. The systems should have the capability of communicating 

across county or at state lines. 1

According to the Health Resources and Services Administration (HRSA), “medically 

underserved” communities may be rural or urban in nature, and consist of residents 

experiencing a shortage of personal health services such as primary, mental or dental 

services, and may face cultural, linguistic, or economic barriers. See HRSA Definitions 

in Appendix A. 

VA has always recognized that special care and attention is needed to address health 

delivery to these target populations. For instance, as part of the dramatic 

transformation of the Veterans Health Administration (VHA) health care delivery of the 

1990’s under the direction of Kenneth W. Kizer, M.D., M.P.H, the homeless veteran was 

recognized as an important recipient of VHA care. Half a decade ago, in Dr. Kizer’s 

testimony to the U.S. House of Representatives Committee on Veterans Affairs’ 

Subcommittee on Health, he stated VHA’s fifth goal as: 

VHA’s fifth mission is to provide medical services and other support for homeless 

veterans. Today, VHA is the single largest direct care provider for homeless 

persons in the country, and we are a critically important – although often 

unrecognized – element in the nation’s public safety net. 2

Likewise, at the 2004 National meeting of the VA Health Services Research and 

Development, VA researchers presented a study that demonstrated that health status 

scores are lower for veterans that live in rural settings when compared to scores for 

1

 The Rural Public Health Research Agenda, 2004, Bridging The Health Divide, University of Pittsburgh Center for 

Rural Health Practice, pp. 4-5 22 Statement of Kenneth W. Kizer, M.D., M.P.H. Under Secretary For Health Department of Veterans Affairs on the

Future of the Veterans Healthcare System before the Committee on Veterans Affairs’ Subcommittee on Health U.S. 

House of Representatives June 17, 1998

6
other veterans. The study concluded that “innovative” strategies are needed to address 

the health needs of these veterans. An example of current innovation within VA is the 

creation of VHA Telehealth Toolkits (e.g., Telemental Health Toolkit, Teledermatology 

Toolkit, and Home Telehealth Toolkit.) These toolkits help VA provide timely, 

accessible, and convenient health care in a safe, appropriate, and cost-effective 

manner.3

The provision of telehealth technologies to veterans located in rural areas is but one 

area where VA has taken an active role to provide affordable technologies to address 

the needs of this population. On-going collaborations that will share the benefit of VA 

electronic health record capability with expanded populations provide other examples. 

VA is presently working with HHS Centers for Medicare and Medicaid Services (CMS) 

to develop a public domain electronic health record optimized for office-based practices 

and clinics. This tool, which would be available at substantially less expense then a 

commercial product, could directly support care to rural veterans and others who 

ordinarily would not benefit from such capabilities. It also would provide a strong basis 

from which VA could transfer lessons-learned and knowledge to other organizations and 

partners who work with rural and medically underserved communities. 

Today VA continues to provide special programs and initiatives specifically designed to 

help homeless veterans live as self-sufficiently and independently as possible. 

Although limited to veterans and their dependents, VA's major homeless-specific 

programs constitute the largest integrated network of homeless treatment and 

assistance services in the country. The program includes aggressive outreach, clinical 

assessment and referral for healthcare, long-term case management and rehabilitation, 

employment and housing support. 4

 

VA’s success in providing health care services to populations that have challenges in 

seeking their own health care services within the traditional hospital and clinic 

environments is well documented. Approaches such as equipping mobile vans with 

clinical and patient care technologies provide unparalleled care in the veterans’ home 

communities. VA has great breadth and depth in experience using health information 

technologies to support such programs. VA is well-poised to share its experience 

across government lines and in cooperation with DoD for the benefit of those rural and 

medically underserved communities that remain out of reach of traditional medicine 

delivery methods. 

VA is reaching out through the State Veterans Homes by providing access to VistA for 

implementation as well as providing access to clinical information for those veterans 

residing in State Veterans Homes. VA supports The Computerized Patient Record 

System (CPRS) Read Only as a software tool which enables medical centers to grant 

 

3 http://vaww.va.gov/telehealth/toolkits.htm 4

4http://vaww1.va.gov/homeless/ 

7
authorized users read-only access to veterans’ individually-identifiable health 

information, and to restrict a user’s access to a specific set of patient records. Over 50 

State Veterans Homes now have CPRS Read Only access. Over 100 State Veterans 

Homes have expressed an interest in obtaining CPRS Read Only access to patient data 

in VistA for a limited number of their clinical staff. Work is proceeding to expand access 

in order to facilitate continuity of care. 

III. THE VA ELECTRONIC HEALTH RECORD 

VA is a leader in the provision of a world-class electronic health record (EHR). 

Recently, the Institute of Medicine (IOM) noted “VA’s integrated health information 

system, including its framework for using performance measures to improve quality, is 

considered one of the best in the nation.” Moreover, a 2004 survey conducted by the 

American College of Physician Executives resulted in the finding that while many 

physician executives and doctors “loathe” clinical information systems, VA clinicians 

provided a “notable outlier from the nexus of negativity.”5

 

The current system, VistA provides clinical, financial and management system for the 

entire enterprise. VistA has enabled organizational transformation by providing the 

ability to respond to contemporary best practices with quantifiable system-wide 

measurement. An IOM Report provides that the single most important safety gain that 

could be realized by technology is the act of providers entering their own orders. VA 

had already implemented order entry; VistA permitted VA to quickly measure 

compliance across the enterprise and make the compliance measurement a 

performance measure for hospital directors and their supervisors. Utilizing VistA, VA is 

able to determine that VA’s current measure of direct order entry of medication orders is 

at 93 percent. Other forms of quality performance measures are employed throughout 

VA and supported by VistA. 

 CPRSis the medical record component. CPRS is currently used in outpatient, 

inpatient, Mental Health, intensive care unit (ICU), Emergency Department, Clinic, 

Homecare, Nursing Home and other diverse environments. CPRS contains all 

components of the medical record, including but not limited to, laboratory, test results, 

medical images, decision support, bar code medication administration, progress notes, 

and appointments. CPRS permits VA clinicians to access a patient’s record from 

anywhere within the health enterprise, at the point-of-care. 

 

5

 Weber, David O., Survey Reveals Physicians’ Love/Hate Relationship with Technology, The Physician Executive, 

March/April 2004. 

8
VA is presently improving and modernizing VistA. VA is migrating its present-day VistA 

system to HealtheVet-VistA. HealtheVet-VistA will consist of VistA upon an improved 

platform that will be built with modern day information tools and languages. Most 

importantly, HealtheVet-VistA will utilize an enterprise architecture constructed to 

standardize data and core communications. HealtheVet-VistA will move away from a 

facility-centric model of data utilization to a patient-centric model that supports the realtime provision of health data to the point of care, wherever it is needed. 

The IOM has identified the eight core capabilities that EHRs should possess. A crosswalk between the target IOM EHR and current VA EHR capabilities demonstrate that 

VA has achieved a “gold standard” EHR. See Table 1, below. 

Reporting (e.g., disease surveillance, patient safety) 9

Administrative processes (e.g., scheduling) 9

Patient support 9

Electronic communication and connectivity 9

Decision support 9

Orders management 9

Results management 9

Health information and data 9

IOM EHR Capability CPRS Capability

Table 1

EHR Capabilities

Table 1, EHR Capabilities 

Utilization of VA’s EHR has yielded tremendous benefits to clinical care and permits VA 

to capture data for virtually every clinical performance measure. For instance, a 

comparison of VA patient care quality data from 2003 with Medicare data from 2003, 

and with the best reported performance of other health care systems in the U.S., shows 

that VA care sets the benchmark for every one of these clinical performance indicators. 

See Table 2, Comparison of Performance Indicators. 

9
VA’s Performance Compared to Non VA 

Footnotes describe adjustments made to match indicator measures as closely as possible with Non VA benchmarks. 

CLINICAL PERFORMANCE INDICATOR VA Base (FY) VA

2002 

VA

2003 Medicare 2003 Best Reported 

Not VA or Medicare 

 

Beta blocker on discharge after AMI 70% (96) 97% 98% 93% 94% NCQA (2002)

Breast cancer screening 68% (96) 80% 84% 75% 75% NCQA (2002)

Cervical cancer screening 64% (96) 89% 90% 62% 81% NCQA (2002)

Cholesterol screening in all patients 84% (00) 91% 91% NA 73% BRFSS (1) (2001)

Cholesterol measured after AMI (2) 85% (00) 92% 94% 78% 79% NCQA (2002)

LDL Cholesterol less than 130 after AMI (2) 67% (00) 74% 78% 62% 61% NCQA (2002)

Colorectal cancer screening 34% (96) 64% 67% NA 49% BRFSS (1) (2002)

Diabetes: HgbA1c done past year 59% (95) 94% 94% 85% 83% NCQA (2002)

Diabetes: Poor control (lower is better) 23% (99) 17% 15% NA 34% NCQA (2002)

Diabetes: Cholesterol (LDL-C) measured 64% (98) 94% 95% 88% 85% NCQA (2002)

Diabetes: Cholesterol (LDL-C) controlled 

(<130) 23% (98) 70% 77% 63% 55% NCQA (2002)

Diabetes: Eye Exam 44% (95) 72% 75% 68% 52% NCQA (2002)

Diabetes: Renal Exam 36% (98) 78% 70% (3) 57% 52% NCQA (2002)

Hypertension: BP <= 140/90 most recent visit

(4) 46% (00) 55% 68% 57% 58% NCQA (2002)

Immunizations: influenza, patients 65 and 

older (5) 27% (96) 74% 76% 69% 68% BRFSS (1) (2002)

Immunizations: pneumococcal, patients 65

and older (5) 26% (96) 87% 90% 65% 72.5% BRFSS (6) (2002)

Mental Health follow-up within 30 days of 

inpatient discharge 

72% (98) 81% 77% 61% 74% NCQA (2002)

1) BRFSS scores are medians, VA scores are averages

2) VA evaluates cholesterol every 2 years ongoing (FY 01 if ever an AMI; FY 02 if AMI in past 5 years); NCQA evaluates 1st year after AMI only.

3) Drop in scores from 2002 levels are attributable to change in scoring methodology and not indicative of drop in performance. 

4) VA Baseline reflects data collected based on a BP < 140/90. NCQA and VA changed in 02 to include both < and = in 2002. 

5) For this comparison the score shown for the VA was calculated utilizing the NCQA methodology. It varies from the score on the Network 

Directors Performance Plan which includes additional populations (high risk patients regardless of age).

6) Represents "best" state results

SOURCE: VHA Office of Quality and Performance 

10
IV. VA/DoD COLLABORATIVE APPROACHES TO FACILITATE THE TRANSFER OF 

AFFORDABLE HEALTH INFORMATION TECHNOLOGIES 

VA and DoD each have a lengthy and comprehensive history developing and 

implementing electronic health record systems. This history translates into significant 

purchasing power and intellectual capital capable of exerting influence upon the health 

information technology (IT) industry as a whole. VA and DoD are the largest providers 

of health care in the United States. They have combined annual health care budgets in 

excess of $50 billion dollars, close to 12 million beneficiaries, and approximately 1600 

health care sites and locations. Jointly and separately the Departments could exert 

significant influence of the provision of affordable technologies to the rural and medically

underserved populations of this Nation. 

A. Knowledge Transfer of Information Exchange Lessons 

The Departments have made significant progress with development of electronic data 

exchanges. As such, VA and DoD are major catalysts in moving the industry toward 

use of interoperable health information technologies that improve health care delivery, 

patient safety and population health management. Within the Departments, the focus of 

this work has been on the creation of a seamless transition for those military service 

members who separate from service and seek care from VA. VA and DoD believe that 

their model of cooperation and joint development work can serve as a model among 

Federal agencies and for national cooperation. 

In April 2002, the Departments adopted a strategy to develop interoperable electronic 

health records in 2005. This cross-cutting initiative, the VA/DoD Joint Electronic Health 

Records Plan, - HealthePeople (Federal), brings together the common adoption of 

standards, the development of interoperable data repositories, and joint or collaborative 

development of software applications to build a replicable model of data exchange 

technologies. 

Federal Health Information Exchange 

As part of this Plan, the Departments have worked on and are planning a series of 

progressive data exchange initiatives. In May of 2002, the Departments began the 

electronic transfer of clinical information from DoD to VA on separated or retired service 

members. As of June 2004, DoD has transferred clinical information on over 2.27 

million prior service members to VA through the Federal Health Information Exchange 

(FHIE). FHIE continues to transfer clinical information from the DoD Composite 

11
Healthcare System (CHCS) to the FHIE Data Repository, where it is available for 

viewing by VA clinicians using VA’s CPRS. Claims adjudicators from the Veterans 

Benefit Administration also may access FHIE data using the Compensation and 

Pension Records Interchange system. The data available includes laboratory results, 

outpatient government and retail pharmacy prescriptions, radiology reports, admission, 

disposition and transfer messages, discharge summaries, consult reports, and 

outpatient coding elements from the Standard Ambulatory Data Record. 

CHCS/VistA Data Sharing Interface 

The Departments are presently engaged in the next step of their data exchange work: 

development of a real time bi-directional exchange of limited data sets for shared 

patients. The CHCS/VistA Data Sharing Interface (DSI) work will leverage already 

developed joint DoD/VA infrastructure, IT investments, VA/DoD test facilities, and 

existing personnel resources to quickly create a real-time, bi-directional interface. DSI 

will permit a Military Treatment Facility to share clinical data capable of computational 

actions with any VA medical center where a shared patient presents for care. 

Other efforts under exploration include two projects in Hawaii. The first project includes 

development work that permits electronic transmission of pharmacy orders between 

Tripler Army Medical Center and VA Honolulu Medical Center for dispensing. This 

interface allows pharmacy orders written at the DoD facility to be transmitted 

electronically and filled at VA pharmacy. The second project, Janus, allows DoD 

providers to retrieve patient data from the VA’s VistA patient record system. It provides 

a single Graphical User Interface (GUI) front end that links to a web application to pull 

data from VistA, to provide end-users on Tripler’s CHCS with VistA patient record 

information. 

Clinical Data Repository/Health Data Repository Interoperability

Beyond bi-directional data exchange in present systems, the Departments also are 

developing an interface between the DoD Clinical Data Repository of the Composite 

Health Care System II (CHCS II) and the VA Health Data Repository of HealtheVetVistA. This initiative, known as “CHDR” (Clinical Data Repository/Health Data 

Repository) will support the real time bi-directional exchange of health data by the end 

of FY 2005. Phase I of this effort is the acquisition of a pharmacy prototype that will 

demonstrate the bi-directional exchange of computable outpatient pharmacy data, 

allergy information, and patient demographics in a lab environment by October 2004. 

The prototype is under development and on schedule. Phase II is the further 

development of the CHDR interface to enable its use in clinical settings. Using clinical

decision support applications, providers in both Departments will be able to access and

12
use relevant clinical data to make important medical decisions for their patients, 

regardless of whether that information resides in VA or DoD systems. 

Other Technologies 

In addition to the data exchange initiatives that support data transfer of multiple clinical 

data sets, VA and DoD have completed and/or are enhancing several other 

technologies that support data exchange: 

o Laboratory: Laboratory Data Sharing and Interoperability (LDSI) software 

permits electronic ordering of labs and results retrieval and permits the 

Departments to use one another as reference laboratories. This 

electronic capability eliminates the manual re-keying of data and 

contributes to patient safety. 

o Credentialing: The Departments are demonstrating the use of a jointly 

developed interface between the DoD Centralized Credentials Quality 

Assurance System and the VA VetPro Credentialing system. This 

credentialing interface decreases the time and resources needed to 

process credentialed providers who practice in both VA/DoD health care 

settings.

o Outpatient Pharmacy: The Consolidated Mail Out Pharmacy (CMOP) 

application was jointly developed and is in use at three joint locations. 

CMOP supports VA’s refilling of outpatient prescription medications from 

DoD’s MTFs at the option of the beneficiary. 

Much of this work can be shared with regional, state, and local entities through 

knowledge transfer of lessons learned. Both Departments are active in organizations 

and forums such as Healthcare Information and Management Systems Society and the 

annual Toward an Electronic Patient Record conference, and routinely share 

experiences at both national and local level industry events. 

B. Adoption of Common Standards and Terminologies 

VA and DoD have achieved the common adoption of an initial set of standards through 

the Consolidated Health Informatics (CHI) initiative. See Table 3. In partnership with 

HHS, VA and DoD are lead partners in the CHI project, one of the 24 eGov initiatives 

supporting the President’s Management Agenda. The goal of the CHI initiative is to 

establish Federal health information interoperability standards as the basis for electronic 

health data transfer in Federal health activities and projects. 

DoD and VA have established an initial joint strategy for data standards which focuses 

on maximizing the utilization of the CHI standards in future systems development and 

13
acquisitions and influencing Standards Development Organizations (SDOs) in further 

standards work. The Target List of VA/DoD standards is attached at Appendix B. This 

Federal government effort has the potential to catalyze industry to adopt common 

terminologies and standards, thereby reducing software development costs and 

producing more affordable electronic health record technologies. 

Table 3 Approved and Adopted CHI Standards 

Standard Description 

HL7 2.4 and

higher XML 

Health Level 7 messaging standards to ensure that each Federal agency can share

information that will improve coordinated care for patients such as entries of orders, 

scheduling appointments and tests and better coordination of the admittance, discharge

and transfer of patients. 

Health Level & vocabulary standards for demographic information, units of measure,

immunizations, and clinical encounter and HL7 Clinical Document Architecture standard

for text base reports. 

NCDCP 

Scripts 

Certain National Council on Prescription Drug Programs (NCDCP) standards for

ordering drugs from retail pharmacies to standardize information between health care

providers and the pharmacies. These standards already have been adopted under the

Health Insurance Portability and Accountability Act (HIPAA) of 1996, and will be

adopted in the three Federal departments that aren't covered by HIPAA will also use the

same standards. 

IEEE1073 The Institute of Electrical and Electronics Engineers 1073 (IEEE1073) series of

standards that allow for health care providers to plug medical devices into information

and computer systems that allow health care providers to monitor information from an

ICU or through telehealth services on Indian reservations, and in other circumstances. 

LOINC Laboratory Logical Observation Identifier Name Codes (LOINC) to standardize the

electronic exchange of clinical laboratory results. 

DICOM Digital Imaging Communications in Medicine (DICOM) standards that enable images

and associated diagnostic information to be retrieved and transferred from various

manufacturers' devices as well as medical staff workstations. 

SNOMED-CT The College of American Pathologists Systematized Nomenclature Medicine Clinical

Terms (SNOMED-CT) for laboratory results contents, non-laboratory interventions and

procedures, anatomy, diagnosis and problems, and nursing.

 

HIPAA The Health Insurance Portability and Accountability Act (HIPAA) transactions and code

sets for electronic exchange of health related information to perform billing and

administrative functions. These are the same standards now required under HIPAA for

health plans, health clearinghouses and those health care providers who engage in

certain electronic transactions. 

14
Standard Description 

Federal

Terminologies

A set of Federal terminologies related to medications, including the Food and Drug

Administration’s names and codes for ingredients, manufactured dosage forms, drug

products and medication packages the National Library of Medicine’s RxNORM for 

describing clinical drugs and the VA’s National Drug File Reference Terminology (NDFRT) for specific drug classifications. 

HUGN The Human Gene Nomenclature (HUGN) for exchanging information regarding the role

of genes in biomedical research in the federal sector. 

EPA 

Substance 

Abuse 

Registry

System 

The Environmental Protection Agency’s Substance Registry System for non-medicinal 

chemicals of importance to health care. 

VA and DoD work with the American National Standards Institute’s (ANSI) and 

Healthcare Informatics Standards Board (HISB) to influence the adoption and 

implementation of nationally and internationally approved standards. Both VA and DoD 

participate on the Health Level Seven (HL7), an ANSI-accredited SDO that is working 

across the industry to establish a set of standard functions for electronic records. A VA

nurse informaticist co-chairs the HL7 Electronic Health Record work group. VA and 

DoD representatives jointly chair the Governmental Projects Special Interest Group. VA

representatives also co-chair the Conformance Special Interest Group, the Patient 

Administration Technical Committee, and Process Improvement. 

VA and DoD also participate in the National Health Information Infrastructure (NHII) 

Taskforce. 

The focus of the taskforce is on activities to help the health care industry create and 

adopt a national health information infrastructure. The purpose is to create a 

comprehensive knowledge-based network of interoperable systems capable of 

providing information for sound decision support available anywhere and at any time it 

is needed. 

The benefits of NHII would be: 

• Improved patient safety; 

• Improved quality of care; 

• Effectively shared decision support; 

• Better understanding of health care costs; 

• Monitored and protected pubic health; and 

• Better informed health care consumers.

VA and DoD are working to define Department enterprise architectures that will fully 

align with the lines of business within each organization, including the delivery of health 

15
care. VA and DoD are working closely to ensure that both enterprise architectures 

support health data interoperability as well as optimal information management to 

support shared care delivery. 

Recognizing the value that coordinated delivery of health care would bring to our 

Nation, VA and DoD are actively engaged with HHS in the Federal Health Architecture 

(FHA) initiative. As co-leads of the electronic health record FHA subgroup, the 

Departments ensure that FHA activities are closely tied to Federal EHR initiatives. The 

FHA initiative has as its goals: 1) improved coordination and collaboration on 

government health IT solutions and investments; and 2) improved efficiency, 

standardization, reliability, and availability of comprehensive health information 

solutions. Part of this work includes identifying relevant data and technical industry 

standards, including those set by the private sector, that would support identified 

Federal business requirements. 

The Departments’ independent and collaborative efforts toward standards and 

architecture could serve as a model for local or regional architecture efforts in 

communities, and between private sector health care providers. Further, as is identified 

by the FHA initiative, a published Federal architecture based on common standards 

could induce private sector technology firms to reduce software development costs. 

This savings would then be passed on to health care providers across all settings, 

including those settings that necessarily rely on government (e.g., Federal, local or 

state) funding and assistance. 

In addition to the joint work in this area conducted by VA and DoD, VA works with other 

Federal partners to promote the shared use of standards and terminologies. These 

efforts are represented in Appendix C. Through the above mentioned areas and 

participation in other varied professional and standards development organizations, VA 

and DoD seek to influence local, state, and national agencies as well as private industry 

to cooperate in adopting and implementing common standards. 

C. TeleHealth Technologies Used for Long Distance Consultations and Distance 

Learning 

Telehealth applications have been successfully utilized to extend medicine to remote 

areas of the world, disaster assistance teams, and ships at sea. Thus, telehealth 

technologies are uniquely suited to support the delivery of health care to rural and 

medically underserved populations that experience shortages in qualified resources 

within their local communities. Telehealth is defined as the use of electronic information 

and telecommunications technologies to support long-distance clinical health care, 

patient and professional health-related education, public health and health 

administration. VA and DoD have several successful joint ventures in using telehealth 

technologies, as outlined in Appendix D. 

16
V. OTHER VA APPROACHES – Knowledge and Technology Transfers to Benefit 

Target Populations 

VA is a leader and innovator in the development of electronic health records, such as 

present system VistA and CPRS, as well as planned future systems HealtheVet-VistA 

and re-engineered CPRS. VA already has realized the target benefits of adopting 

EHRs and therefore is well-poised to participate in the expansion and integration of 

such technologies to larger health communities. 

The universe of VA health care encompasses approximately 1300 sites of care that 

include 158 hospitals, over 850 community-based outpatient clinics, as well as nursing 

homes, domiciliaries, Vet Centers, and residential rehabilitation treatment programs. VA

provides treatment to almost 5 million veterans each year among our 7.5 million veteran 

enrollees, who are older, sicker, and poorer than the age-matched U.S. population. 

This feat is made possible by VistA and other electronic health technologies. 

Much of VA’s VistA system was developed by VA government resources and therefore, 

the software exists in the public domain. Through on-going and active collaborations 

with a number of government and private-sector resources, VA encourages the 

proliferation of public domain technologies based on VistA code. This approach 

reduces expensive development costs associated with software and human capital 

requirements, and makes proven EHR technology an affordable and direct-transfer 

option to rural and medically underserved communities. 

In addition to health information technology development, VA is a leader in large scale 

health information system implementation without compromise to patient safety or 

medical care. To the contrary, VA system implementation has improved the quality of 

care in measurable ways due, in large part, to data made available by VistA. As a result 

of this extensive system implementation experience, VA has also learned important 

lessons about the challenges of applying new technologies to existing clinical 

environments. VA has successfully taken a legacy system, the Decentralized Hospital 

Computer Program, and transformed it into modern VistA. A future version HealtheVetVistA will soon be available and our public domain version of VistA, HealthePeopleVistA, is growing through national interest and collaboration opportunities. 

VA shares these lessons in a number of forums. The following are examples of VA 

health information technologies that should be considered for coordinated knowledge 

and technology transfers to support these populations. 

A. VistA for Use in Office-Based Practices and Clinics 

In cooperation with HHS, VA is presently developing a public domain electronic health 

record based on core VistA technology. This project, will develop a product for release, 

17
within the next 12 months that will be suitable for use in office-based practices and 

clinics, and for use in collecting quality measurements of health data. As public domain 

software, this VistA-based tool will provide an affordable option for technology

acquisition by decreasing resources necessary for installation and maintenance and will 

support the delivery of health technology benefits to all Americans. Planned 

enhancements include a) enhancing the registration capabilities of the VistA product to 

meet the needs of clinicians in office-based practices and clinics , b) enhancing the 

OB/GYN and Pediatrics components of current VistA, c) simplifying VistA so that its 

installation and maintenance is easier, d) improving the management of chronic 

diseases and e) providing for communication of outcome measures to a Quality 

Improvement Clinical Data Warehouse. Such a tool may be adopted directly by 

physicians and clinics, or acquired by private sector entities that support them. 

Other on-going examples of public domain technology transfers that could benefit rural 

and medically underserved communities, as well as the larger health community, are 

included in Appendix E. 

B. My HealtheVet - The Personal Health Record 

Personal health records are an important component of the provision of health 

information technologies. Personal health records provide patients the tool to collect 

and maintain personal health information and encourage active involvement in health 

care decisions that impact them. On Veterans Day 2003, VA released Phase 1 of My 

HealtheVet, a personal health record tool for veterans. Functional capabilities include: 

secure personal health journal, 18 million pages health and wellness information, 

benefits information, and online drug interaction checker. Future capabilities will 

include: online primary care appointing, Web-based pharmacy refill and renewal, 

appointment reminder, structured provider to patient messaging, and secure provider 

access to CPRS/VistA. 

My HealtheVet will transform the delivery and management of care into a collaborative 

venture as veterans will eventually choose to share all or part of their information with 

family members, health advocates, or other private health care providers. This forwardthinking concept, that veterans are active participants, partners, and managers of their 

own health care, should be highlighted and explored for application to target 

communities. 

C. Bar Code Medication Administration 

Within hospitals, medication administration errors lend a substantial contribution to the 

rate of morbidity and mortality. One innovative technology developed and utilized by VA 

to address this is the VA Bar Code Medication Administration System (BCMA). BCMA 

was developed based on a prototype project created at the Colmery-O-Neil Veterans 

18
Affairs Medical Center. BCMA is a wireless, point of care technology that uses an 

integrated bar code scanner. The bar scanner permits nurses to scan patient 

wristbands and medications while the software “checks” the transaction and validates 

what was given against the electronically stored order. BCMA ensures that each patient 

receives the correct medication and dose at the correct time by eliminating the need for 

reliance on short-term memory. BCMA technology will alert the nurse administering a 

medication if the software detects a mismatch between the identified patient and 

ordered medication dosage, time, or drug. Order changes and updates are 

electronically communicated to the nurse thereby eliminating time delays and increasing 

administration accuracy. Allergies, adverse reactions and special instructions also are 

tracked by BCMA as well as order changes that require staff attention. BCMA is fully 

compatible with VistA and CPRS. 

VA-developed BCMA technology could greatly improve the efficiency by which care is 

delivered in hospitals and other settings across sites. Benefits include: 

• Increasing accuracy of medication administration; 

• Increasing the information available to clinical staff at the patient point-ofcare; 

• Reducing wasted medications; 

• Improving communication between Nursing and Pharmacy staffs; 

• Providing a real-time list of orders for medication administration; 

• Recording refused and held medications and reasons; 

• Recording missing doses and sending the request electronically to the 

Pharmacy; and 

• Providing a point-of-care, real time data entry/retrieval system. 

D. Telehealth/Telemedicine 

Telehealth makes up a significant component in how VA intends to fulfill its mission to 

care for veteran patients. Telehealth involves the provision of health care services 

when patient and provider are separated in time and/or place, and take place using 

electronic media. Telemedicine is included within the broader rubric of telehealth. 

Within VA, telehealth transactions most often involve care between all professional 

groups and patients, not just physicians. The expansion of telehealth is an important 

part of the mission of VA, and directly supports coordinated delivery of care. 

There are significant clinical and business barriers to the expansion of telehealth 

services that VA is addressing. For instance, outside of federal health care delivery 

locations, state licensure requirements often prohibit practice of medicine or nursing 

across state lines. Inadequate coding and reimbursement structures are examples of 

business barriers to telemedicine expansion. 

19
The computerized medical record is a critical component to VA’s strategy for the 

expansion of telehealth. For example, using videoconferencing to connect a patient 

with a provider situated many hundreds of miles away could not take place safely and 

effectively without having the patient’s health record, laboratory results and clinical 

images available. This transaction would be of greater benefit if the medical record 

existed in multi-media format. 

The concept of telehealth in VA is absolutely congruent with VA’s transition to a 

computerized patient health record from a computerized patient medical record. This 

record is currently configured to operate within the context of clinics and hospitals. VA 

is working to expand the concept of the multi-media record into the home using hometelehealth technologies and My HealtheVet. In VA, technology is not the driver; rather, 

technology is supportive of the way in which VA meets the changing nature of the health 

needs of veteran patients. Veteran patients have predominantly chronic diseases that 

are being treated in non-hospital settings. VA telehealth is expanding to meet these 

needs in the settings where they are needed most. 

E. VistA Imaging Technology

The VistA Imaging System is a system that enables the sharing, storing and retrieval of 

clinical images. VistA Imaging is a critical component to the VA vision of the multimedia patient health record; it will support both conventional and telehealth-based 

health care delivery. 

VistA Imaging is a VA developed tool that integrates traditional medical chart 

information with medical images of all kinds, including x-rays, pathology slides, 

cardiology motion views, wound photos, and pictures acquired during endoscopy, 

surgery, and eye exams. Document scanning incorporates handwritten records, 

diagrams, and outside medical reports in online records. VistA Imaging permits a 

remote consulting physician to have access to clinical images for diagnosis and 

treatment – an invaluable tool for the provision of care to remote rural and medically 

underserved populations. VistA Imaging workstations are deployed throughout VA 

hospitals to capture and display medical images from across multiple specialties. VistA 

Imaging also uses the Digital Imaging and Communications in Medicine (DICOM) 

standards to interface directly other imaging equipment including CT, MRI, Ultrasound 

and X-ray. 

F. Support of Community and Regional Setting Broad Data Exchange Initiatives 

VA presently participates in a number of data exchange initiatives that involve 

community-based private or government organizations. Although VA is not exchanging 

data with these organizations per se, close collaboration provides invaluable technology 

20
transfer and data exchange lessons (e.g., data security and patient privacy lessons) in 

settings where they are needed, improving patient care to the those populations within 

the communities and serving as a framework model of collaboration that other 

communities could replicate. Examples of on-going data exchange initiatives are 

included in Appendix F. 

G. Contracting Incentives With Private Providers 

As a purchaser of clinical services, the Federal government contracts with private sector 

providers to deliver care to its covered lives. In developing contracting incentives with 

private providers, initial activity within VA will include assessing all contracts for covered 

care. Potential benefits to be gained from incentives for use of health IT within these 

contracts include gains in quality and efficiency in caring for covered veterans. VA 

recognizes strong similarities between the use of incentives within contracting and the 

incentives within reimbursement. In an effort to foster strategic alignment and to 

decrease the risk of multiple Federal incentives methodologies impacting the VA 

business partners, VA will explore aligning its contract incentives with the 

reimbursement incentives as established by CMS, DoD, and other Federal agencies. 

VI. Summary and Recommendations 

VA and DoD are the largest health care providers in the Nation. As such, they are 

uniquely positioned to influence health delivery from a national standpoint. In 

consideration of the identified joint approaches the Departments could take to make 

affordable health technologies available to rural and medically underserved 

communities, the following is recommended: 

o Capture lessons learned, including technical and resource identification, of data 

sharing initiatives. Where appropriate, conduct technology transfers to private 

sector and state and local levels as a means of providing affordable technologies 

to these areas. 

o Continue joint standards adoption work to leverage the immense capability to 

influence the vendor community in the development of affordable health 

technologies. 

o Continue utilization and development of telehealth technologies to be used in the 

direct provision of care to geographically remote areas, and areas that are 

underserved by health delivery services. 

In addition to the joint work conducted with DoD, VA is a recognized leader in the 

development of health information technologies and health information systems. As 

such, VA is well positioned to do the following: 

21
 Continue efforts to share health information technologies that are free and 

available to the general health care community at no cost for the benefit of all 

patients. This will be accomplished through the continued development of 

electronic health record software and technologies, and interoperable health 

applications. Continue to support the development of software that remains in 

the public domain. These include VistA, HealtheVet-VistA, HealthePeople-VistA, 

the collaborative HHS/VA VistA-based tool for office-based practices and clinics, 

and CPRS. 

 Continue development of health information technologies that assist in the 

provision of care to remote populations. These include VistA Imaging and 

telehealth applications. 

 Continue active collaborations with regional and community based health 

organizations that transfer technologies, explore data standardization efforts, 

and increase effective health data sharing. 

 Continue development and enhancement of personal health record technologies, 

such as My HealtheVet, which empower veterans and health care consumers to 

become active participants in the health delivery process. 

 Capture and transfer important lessons-learned from extensive system 

implementation and migration. 

22
APPENDIX A - DEFINITIONS (Health Resources and Services Administration) 

i. Medically Underserved Areas (MUA) may be a whole county or a group of 

contiguous counties, a group of county or civil divisions or a group of urban census 

tracts in which residents have a shortage of personal health services. 

ii. Health Professional Shortage Areas (HPSAs) may have shortages of primary 

medical care, dental or mental health providers and may be urban or rural areas, 

population groups or medical or other public facilities. 

iii. Medically Underserved Populations (MUPs) may include groups of persons who 

face economic, cultural or linguistic barriers to health care. 

23
APPENDIX B - TARGET VA/DoD STANDARDS PROFILE 

Standards Relevant to Information Sharing 

Category/Subcategory

Service Area Standards

Information Standards

Message Format 

Clinical Information

Electronic Data 

Interchange (EDI) 

HL7 v2.4 (XML encoding preferred) 

Medical EDI ANSI ASC X12N 270, 271, 276, 277, 278, 820, 834, 835, 837 

FIPS Pub 161-2 

NCPDP Telecommunication Standard Implementation Guide v5.1

HL7 v2.4 (XML encoding preferred) 

Medical Still-Imagery EDI DICOM v3.0 

JPEG 2000 

Data Representation Standards 

Clinical Data 

Representation

Drug Codes NDC

Lab and Clinical 

Observation Codes 

LOINC 

Mental Disorder Codes DSM-IV 

Multiaxial Medical

Nomenclature

SNOMED, SNOMED-RT 

Outpatient Procedure CPT-4

Patient Diagnosis ICD-9-CM

Dental Codes CDT-4 

Ancillary Services

Reporting and Claims 

Processing 

HCPCS 

Revenue Codes and 

Workload Weights 

RBRVS 

24
Standards Relevant to Information Sharing 

Category/Subcategory

Service Area Standards

Information Modeling 

and Metadata 

Object and Data Modeling FIPS Pub 184 (IDEF1X) 

OMG UML v1.4

OMG XMI 

Security Standards 

Authentication FIPS Pub 83, 112 

IETF RFC 1510, 2138, 2289, 2402, 2633 

ISO/IEC 7816 Parts 1-10 

Open Group C311 

Accountability ISO/IEC 10164-8 

Data Integrity and Nonrepudiation FIPS Pub 180-1, 186-2 

IETF RFC 2246, 2402, 2406, 2633 

IEEE 802.10 

ITU-T X.509 (2000)/ISO/IEC 9594-8:2001 

IETF RFC 2459 

Confidentiality FIPS Pub 46-3, 74 , 140-2 , 185, 186-2 

IETF RFC 2420, 2559, 2633 

ITU-T X.509 (2000)/ISO/IEC 9594-8:2001 

IETF RFC 2459 

Certification ISO/IEC 15408 

FIPS Pub 140-2 

Security Management ISO/IEC 10164-8 

Technical Standards 

Communications

Collaborative

Communications 

ITU-T.120, T.122, T.124, T.125 

Directory Services IETF RFC 1034, 1035 (DNS)

IETF RFC 1777 (LDAP) 

ITU-T X.500 

Internet Transport Services IETF RFC 791, 793, 919, 922, 950, 959, 1112 (TCP/IP) 

IETF RFC 2131 (DHCP) 

IETF RFC 792 (ICMP) 

File Transfer IETF RFC 959, 2228 (FTP) 

Electronic Mail IETF RFC 821, 1869, 1870 (SMTP) 

Video Teleconferencing ITU-T H.221, H.230, H.242, H.243, H.244, H.261, H.263, H.320, 

H.323, G.711, G.722, G.728, T.120, T.122, T.124, T.125 

25
Standards Relevant to Information Sharing 

Category/Subcategory

Service Area Standards

Wireless IEEE 802.11a, 802.11b 

Ethernet Standards ISO/IEC 8802-3 (10-Base-T, Ethernet) 

IEEE 802.3u (100-Base-T, Fast Ethernet) 

IEEE 802.3ab (1000-Base-T, Gigabit Ethernet) 

Object Management

Services 

OMG CORBA v2.3.1 

W3C SOAP 

Web File Sharing IETF RFC 2616 (HTTP) 

ANSI/ISO/IEC 9636 series (CGI) 

Information Processing 

Document Distribution 

Format 

MS Word (.doc) 

Portable Document Format (.PDF)

Rich Text Format (.rtf) 

Data Management

Services 

ISO/IEC 9075-3 

Graphics Data Interchange GIF 

JPEG File Interchange Format v1.02 

Video Compression ISO/IEC 11172-, 2, 3 (MPEG1)

ISO/IEC 13818 series (MPEG2) 

Document Interchange W3C HTML, XML 

Graphics Services ISO/IEC 8632-1, 3, 4 (CGM) 

26
APPENDIX C - VA COLLABORATIVE STANDARDS AND TERMINOLOGY EFFORTS 

i. VA & NLM Memorandum Of Understanding (MOU) – This MOU was put in place to 

establish a mechanism to support shared terminology-related services between the 

National Library of Medicine (NLM), National Institutes of Health (NIH) and VA. 

ii. VA & NCI MOU – This MOU was put in place to support shared drug information and 

terminology-related services between the National Cancer Institute (NCI) and VA. 

iii. VA & FDA MOU – National Drug File – This MOU was put in place to establish a 

formal collaboration between the Food and Drug Administration (FDA) and VA for the 

purpose of developing and implementing terminology standards for medication 

information. 

27
APPENDIX D - VA/DOD TELEHEALTH TECHNOLOGIES 

Teleradiology: Ongoing local initiatives include: 

o Eisenhower Army Medical Center (Fort Gordon, GA) and the Augusta VA 

Medical Center. 

o Blanchfield Army Community Hospital (Fort Campbell, KY) and VA in Kentucky. 

o Moncrief Army Community Hospital (Ft. Jackson, SC) and the Columbia VAMC. 

o The “I-25 Corridor Working Group” has begun connecting together the US Air 

Force Academy Hospital, clinics at Air Force Bases (Buckley, Schriever, 

Peterson, Malmstrom, and FE Warren), Evan Army Hospital (Fort Carson, CO) 

with VA clinics in La Junta and Pueblo CO, and VA Medical Centers in Denver 

CO and Cheyenne WY. This connection will enable the exchange of digital 

radiographs and MRIs. Denver VA Medical Center and US Air Force Academy 

have already starting exchanging images. 

o Sacramento VAMC sends Emergency Room after-hours and weekend x-ray and 

CT images to Travis AFB’s David Grant Medical Center over a point-to-point T1 

line using dynamic compression technology. Radiology residents at DGMC 

make preliminary review and fax results back to VA. Final interpretations and 

dictations are performed by VA radiologists. This helps maintain workload 

requirements for Travis radiology residency program and improves quality of life 

for understaffed VAMC radiologists who have limited on-call responsibilities. 

Telepsychiatry: Weed Army Community Hospital (Ft. Irwin, CA) is working with the 

Los Angeles VA Regional Office to establish a VA/DoD sharing agreement to perform 

Compensation and Pension examinations, utilizing telemedicine for psychiatric 

examinations on persons separating/retiring at Fort Irwin who require such evaluation. 

Hawaii Integrated Federal Health Care Partnership: The Pacific Telehealth and 

Technology Hui was established in 1999 as a joint partnership of the VA Medical and 

Regional Office Center in Honolulu and Tripler Army Medical Center to manage joint 

Telehealth projects involving research, development, prototype, evaluation and 

technology transfer. Some of these efforts include two projects developed under a joint 

initiative with the Joslin Diabetes Center, one of the world’s leading research centers for 

diabetes. 

o The first project, the Joslin Vision Network (JVN), provides a platform for 

assessing the severity of diabetic retinopathy using a highly sophisticated digital 

camera to capture and transmit an image of the retina to a reading station for 

remote evaluation. 

o The second, the joint Hui-Joslin initiative, called the Holopono program, 

demonstrates the use of Internet technology to manage follow-up care for 

patients with diabetes. 

28
Alaska Federal Health Care Access Network: This initiative of the Alaska Federal 

Health Care Partnership is comprised of DoD, VA, Indian Health Service (IHS), the US 

Coast Guard and other state and Federal agencies. Its goal is to use new 

telecommunications and telemedicine technology to extend and improve access to 

health care service and information for over 200,000 Federal beneficiaries, especially 

Indian Health beneficiaries in remote areas. The project has linked 235 Federal and 

state health care sites into a statewide telemedicine system. Using state-of-the-art 

technology and equipment, member organizations have begun to send medical 

images, health information, and voice data to regional hospitals for remote diagnosis 

and consulting. 

Case Management (Diabetes): The Joslin Vision Network (JVN) is a telemedicine

application focused on increasing access of diabetic patients into appropriate eye care 

and represents a collaborative effort between DoD, VA, and Joslin Diabetes Center in 

Boston. The original proof-of-concept JVN system has evolved into a secondgeneration system using non-proprietary Microsoft hardware and software, which 

leverages the established Patient Archiving and Communications System infrastructure 

and implements the Comprehensive Diabetes Management Program proposed in the 

Chronic Care Model developed by Edward Wagner, M.D. Its six components are: (1) 

Coordination with community resources; (2) Strategic commitment of the organization; 

(3) Support of patient self-management; (4) Redesign of delivery system; (5) Clinical 

decision support; and (6) Clinical information systems. The JVN eye care system: 

o Is currently deployed in 32 active remote imaging sites, with six established 

and certified reading centers distributed across ten different states, from 

Hawaii to New England; 

o Represents participating sites associated with the DoD, Veterans Health 

Affairs and the Indian Health Service; 

o Has allowed access to over 12,000 patients into the JVN eye care system 

since September 2001; 

o JVN CDMP application is currently live at the Joslin Diabetes Center and 

Walter Reed Army Medical Center; and 

o Provides significant opportunity, when leveraged with deployed 

teleconsultation systems, to realize substantial cost savings for treating 

chronic disease. 

e-Learning: The Adult Nurse Practitioner Post Master’s Program is a collaborative 

effort between VA and the Graduate School of School of Nursing, Uniformed Services 

University for the Health Sciences (USUHS), which provides a Nurse Practitioner 

Distance Learning educational curriculum for VA and DoD nurses. It demonstrated that 

students and teachers, separated by geographic distance, can participate fully in an 

effective and meaningful educational process using electronic technology for 

communication. To date 70 individuals have graduated; the last class in May 2004. 

This Fall USUHS will enable distance learning in support of the doctoral Nursing 

Science program for DoD and VA nurses. USUHS is also in the process of building a 

29
distance learning component to their Master’s in Public Health program that could be 

utilized by DoD and VA providers. 

30
APPENDIX E - EXAMPLES OF VA PUBLIC DOMAIN TECHNOLOGY TRANSFERS 

i. District of Columbia Government –Implementation of VistA in all DC Department of 

Health clinics over time. There are presently three locations that are fully 

implemented. 

ii. Indian Health Service –Implementation of VistA Imaging and CPRS in Indian Health 

Service. This work also includes the convergence of two systems including: Women’s 

Health; Mental Health; Patient Billing; and CPRS & Health Summaries. 

iii. American Samoa – Implementation of VistA in Samoa LBJ Tropical Medicine 

Hospital. 

iv. State Government Health Departments – Ongoing exploration and/or 

implementation of VistA/CPRS in state government health departments such as 

Washington, West Virginia, Los Angeles County, North Carolina, Rhode Island, and 

Texas. 

v. Association of American Medical Colleges (AAMC)/Affiliated Medical Schools – 

On-going agreement with the AAMC and affiliated medical schools to form a working 

group and select initial pilot sites to explore use of VistA systems. 

31
APPENDIX F - EXAMPLES OF VA DATA EXCHANGE INITIATIVES 

i. VHA & HHS Data Exchange –Currently pilot testing the capability to extract VistA 

data maintained at the national Austin Automation Center to be fed into various public 

health databases and/or biosurveillance systems maintained by HHS, Centers for 

Disease Control (CDC), and State Health Departments, e.g. Bioterrorism/ National 

Electronic Disease Surveillance System. 

ii. Santa Barbara Care Data Exchange Pilot – Preparing to pilot test the exchange of 

patient data between the VA Outpatient Clinic and a number of other partnering public 

and private sector health care organizations in Santa Barbara County, in collaboration 

with the California HealthCare Foundation and CareScience. 

iii. Community Patient Data Exchange Networks – Exploring and collaborating with 

other patient data exchange systems in local communities around the country 

including: 

- Mesa County (California) Care Data Exchange; 

- Patient Safety Institute – Delaware & Puget Sound pilot tests; and 

- Indianapolis (Regenstrief) Patient Data Exchange. 

iv. VA and Center for Disease Control (CDC) - The Department of Homeland Security 

designated CDC as the lead agency in March of 2004. VA has worked with CDC to 

identify a dataset electronically available within its clinical information systems to 

support syndromic analysis. To date, VA is the only multiple site health care 

organization (government or private sector) to successfully transfer data to the CDCs 

Bio-Sense database on a continual basis. VA provided a two-year historical data load 

for CDC to analyze and develop threshold algorithms, and since August 2003, has 

provided nightly uploads of previous daily activity from each medical center (170 

hospitals and 1300+ clinics). 

32
TABLE OF ACRONYMS

Description Acronym 

American National Standards Institute ANSI 

Bar Code Medication Administration 

System 

BCMA 

Centers for Disease Control CDC 

Centers for Medicare and Medicaid 

Services 

CMS 

CHCS-VistA Data Sharing Interface DSI 

Clinical Data Repository/Health Data 

Repository 

CHDR 

Composite Healthcare System CHCS 

Computerized Patient Record System CPRS 

Consolidated Health Informatics CHI 

Consolidated Mail-Out Pharmacy CMOP 

Department of Defense DoD 

Department of Health and Human 

Services 

HHS 

Department of Veterans Affairs VA 

Digital Imaging Communications in 

Medicine 

DICOM 

Electronic Health Record HER 

Environmental Protection Agency EPA 

Federal Health Architecture FHA 

Federal Health Information Exchange FHIE 

Food and Drug Administration FDA 

Graphical User Interface GUI 

Health Insurance Portability and HIPAA 

33
Description Acronym 

Accountability Act 

Health Level 7 HL7 

Health Professional Shortage Areas HPSA 

Health Resources and Services 

Administration 

HRSA 

Healthcare Informatics Standards 

Board 

HISB 

Human Gene Nomenclature HUGN 

Indian Health Service IHS 

Information Technology IT 

Institute of Medicine IOM 

Lab Data Sharing and Interoperability LDSI

Logical Observation Identifier Name 

Codes 

LOINC 

Medically Underserved Areas (MUA) MUA 

Medically Underserved Populations 

(MUPs) 

MUP 

Memorandum of Understanding MOU 

Military Treatment Facility MTF 

National Cancer Institute NCI 

National Council on Prescription Drug 

Programs 

NCPDP 

National Drug File Reference 

Terminology 

NDF-RT 

National Health Information 

Infrastructure 

NHII 

National Library of Medicine NLM 

Office of the National Coordinator for ONCHIT 

34
Description Acronym 

Health Information Technology 

Standards Development Organization SDO 

Systematized Nomenclature Medicine 

Clinical Terms 

SNOMED-CT 

The Institute of Electrical and 

Electronics Engineers 

IEEE 

Uniformed Services University for the 

Health Sciences 

USUHS 

Veterans Health Information Systems 

and Technology Architecture 

VistA 

APPROVE/DISAPPROVE: 

____________________________________ 

Anthony J. Principi Date 

Secretary 

Department of Veterans Affairs 

35
ATTACHMENT 3: 

Report from the Department of Defense 

UNDER SECRETARY OF DEFENSE

4000 DEFENSE PENTAGON

WASHINGTON, D.C. 20301-4000

JUL 1 6 2004

PERSONNEL AND

READINESS

The Honorable Tommy Thompson

Secretary of Department of Health and Human Services

200 Independence Avenue, S. W .

Washington, D.C. 20201

Dear Mr. Secretary

The attached report responds to the President's Executive Order on "Incentives for

the Use of Health Information Technology and Establishing the Position of the National

Health Information Technology Coordinator," dated April 27, 2004. The Executive

Order directed DoD and VA to "report on the approaches the Departments could take to

work more actively with the private sector to make their health information systems

available as an affordable option for providers in rural and medically underserved

communities." DoD has implemented health information technology in remote areas

throughout the world. This experience and lessons learned will be shared with the Office

of the National Coordinator for Health Information Technology (ONCHIT), HHS.

We look forward to our continued collaboration with the Department of Health

and Human Services and the ONCHIT.

~~ 

t7, 12'.<--L-

,--

David S. C. Chu

Attachment:

As stated

Report on Approaches to Work 

with the Private Sector to Make 

Health Information Systems 

Available and Affordable to Rural 

and Medically Underserved 

Communities 

July 6, 2004 
Contents 

I. Executive Summary........................................................................................................ 4

II. Introduction..................................................................................................................... 7 

III. Background..................................................................................................................... 7 

A. Rural and Underserved Requirements......................................................................... 7 

IV. Rural Health and Medically Underserved Target Architecture – “Blueprint” or “Road 

Map” ........................................................................................................................................ 9 

V. Interoperability and Common Standards...................................................................... 10 

A. Interoperability—Data Exchange .............................................................................. 10

1. Federal Health Information Exchange................................................................... 10 

2. Clinical/Health Data Repository............................................................................ 11 

3. Laboratory Data Sharing Interoperability.............................................................. 11 

4. Consolidated Mail Outpatient Pharmacy............................................................... 12 

5. Centralized Credentials Quality Assurance Systems/VetPro ................................ 12 

6. Federal Health Architecture Electronic Health Record Initiative.......................... 12 

B. Data, Security, Technical, and Communication Standards ....................................... 13 

C. Infrastructure Considerations..................................................................................... 14

VI. DoD Health Information Technologies for Use in Different Environments................ 16 

A. Mobile Healthcare Provider Settings......................................................................... 17 

B. Small Family Practice Clinic Setting......................................................................... 17 

C. Large Clinics and Smaller Hospitals ......................................................................... 18 

D. TeleHealth Used for Long Distance Consultations and Distance Learning .............. 19 

VII. Contracting Considerations .......................................................................................... 19

VIII. Summary of Approaches and Knowledge Transfer...................................................... 20 

IX. Considerations and Barriers.......................................................................................... 22 

X. Summary....................................................................................................................... 22 

XI. Appendices ................................................................................................................... 23 

Appendices 

APPENDIX A Definitions.................................................................................................... 23 

APPENDIX B Target DoD Standards Profile ...................................................................... 24 

APPENDIX C VA/DoD Telehealth Projects ....................................................................... 27 

APPENDIX D Benefits of Telehealth .................................................................................. 31 

Tables 

Table 1. Approved and Adopted CHI Standards................................................................... 13 

2
Figures 

Figure 1. Information Technology Infrastructure Components............................................ 16 

Figure 2. Mobile Workstation Model ................................................................................... 17 

Figure 3. Small Family Practice Clinic Model ..................................................................... 18 

3
I. Executive Summary 

By Executive Order, the President directed that the Departments of Veterans 

Affairs (VA) and Defense (DoD) shall jointly report to the Office of the National 

Coordinator for Health Information Technology (ONCHIT) on the approaches the 

Departments could take to transform clinical practice and healthcare delivery in rural 

and medically underserved communities through the use of affordable health 

information systems. This report recommends the need for a common “blueprint” or 

“road map” from which all interested parties can proceed. Further, the report 

recommends approaches that focus on standards (e.g. data, security, messaging, 

technical, and communication) and interoperability; infrastructure considerations 

(e.g., networks, hardware, and software); contracting incentives; technology transfer; 

and sharing of lessons learned. 

DoD and VA serve as catalysts for changing how healthcare is delivered in the 

future; specifically as it relates to the use of health information technologies to 

improve access, healthcare delivery, population health management, and patient 

safety. ONCHIT is coordinating with DoD, VA, other federal agencies and 

organizations to develop: (a) a framework for securely exchanging health data 

through a common federal health infrastructure, (b) electronic health records, and (c) 

standards for data, security, technology, and communication. 

DoD has successfully implemented various types of health information 

technologies in comparable environments and for similar purposes as those found in 

rural and medically underserved communities. Examples of these technologies 

include: 

• Telehealth for radiology, mental health, dermatology, pathology, and 

dental consultations; 

• Online personalized health record for beneficiary use; 

• Bed regulation for disaster planning; 

• Basic patient encounter documentation 

• Pharmacy, radiology, and laboratory order entry and results retrieval for 

use in remote areas and small clinics; 

• Pharmacy, radiology, and laboratory order entry and results retrieval, 

admissions and discharge, and appointments for use in small hospitals; and 

• Online education offerings for healthcare providers 

Technology products, outcomes, benefits, and cumulative knowledge should be 

shared with ONCHIT for use within the private sector and local/state organizations to 

help guide their planning efforts. 

4
In response to the directive, DoD proposes the following approaches: 

• DoD will collaborate and coordinate recommendations with ONCHIT in support 

of the development of a strategic plan. 

• DoD will communicate, encourage, and incentivize industry business partners to 

actively support the President’s agenda. 

• The National Governors’ Association (NGA) or a similar organization should 

establish a consortium of local and state authorities to develop a “blueprint” or 

“road map” targeted at healthcare delivery in rural and medically underserved 

communities – this blueprint will serve as a common business reference point 

from which information technology investment decisions can be made. 

o DoD should share with ONCHIT its health enterprise architecture and 

lessons learned with the NGA consortium, local and state governments, 

and private industry. 

• DoD and VA should continue to aggressively participate with Standard 

Development Organizations (SDOs) in the development of national health data, 

technical, security, and communication standards that foster interoperability and 

data exchange. 

• DoD and VA should continue to work with professional organizations such as 

Health Information Management System Society (HIMSS), American Medical 

Association (AMA), and support initiatives such as National Health Information 

Infrastructure (NHII) to facilitate the adoption and implementation of standards. 

• DoD and VA should continue to share with the private sector experiences and 

lessons learned from the many ongoing health data exchange initiatives. 

• Working with other federal agencies and organizations, DoD should assist in 

drafting templates of standard contract language for use nationally, which 

encourages industry to produce products and services that are scalable and 

applicable to the rural and underserved communities. 

o DoD will develop acquisition selection criteria which favorably consider 

those companies that agree to provide products and services that are 

applicable to targeted communities such as the rural and underserved. 

5
• DoD recommends that the federal government establish regional or national 

contracting and acquisition centers of excellence to strengthen purchasing power 

(e.g., bulk buys) and sharing of contracting language and lessons learned. 

• DoD and VA should share electronically based educational programs that serve to 

extend the use of professionals and paraprofessionals in remote areas and assist 

them in staying current on medically related topics. 

• In coordination with ONCHIT, DoD should share lessons learned and clinical 

practice templates in various forums with national, regional, state, and local 

authorities and the private sector on such topics as: 

o Application of health information technologies in remote sites, 

o Management of information technologies in remote sites, 

o Implementing privacy and security measures, 

o Business process reengineering, 

o Unique infrastructure solutions, 

o Application of health standards in Health Information Technology (HIT), 

o Change management, and 

o Implementation challenges. 

• ONCHIT, with input from DoD and VA, should lead federal efforts to develop 

and implement an electronic health record and common business rules. 

• DoD should develop and implement the use of personal health records (e.g., 

TRICARE Online), demonstrating opportunities to educate providers and 

beneficiaries. 

6
II. Introduction 

On April 27, 2004, President Bush issued the Executive Order “Incentives for 

the Use of Health Information Technology and Establishing the Position of the

National Health Information Technology Coordinator.” The purpose of the Order 

was for “the development of an interoperable health information technology 

infrastructure to improve the quality and efficiency of healthcare.” As part of this 

Order in Section 4(b), the President directed the Secretaries of the Departments of 

Veterans Affairs (VA) and Defense (DoD) to jointly report to the Office of the 

National Coordinator for Health Information Technology (ONCHIT) on the 

approaches the Departments could take to work more actively with the private sector 

to make their health information systems available as an affordable option for 

providers in rural and medically underserved communities. The Order requires the 

Departments to document their approach in a joint report within 90 days, by July 25, 

2004. This report answers that requirement from the DoD perspective. 

III. Background 

As one of the nation’s largest healthcare providers, DoD has a lengthy and 

comprehensive history working in remote and medically underserved areas 

throughout the world in peacetime and wartime. DoD has experience in applying 

innovative business and information technology solutions in such areas as capturing, 

storing, and securely transmitting patient data electronically; keeping providers in 

remote locations trained on the latest advances in medicine; educating patients long 

distance; medical surveillance; deploying unique infrastructure solutions, data 

aggregation and analysis; and conducting long-distance consultations. This history 

translates into significant intellectual capital capable of exerting influence upon the 

health IT industry, specifically for the purpose of improving healthcare, patient safety 

and population health management. 

A. Rural and Underserved Requirements 

Providers in rural and medically underserved communities encounter many and 

varied challenges in serving their communities. (Definitions are found in Appendix 

A.) 

The Rural Public Health Research Agenda of April 2004, held at the University 

of Pittsburgh Center for Rural Health Practice, identified the following core themes 

for Rural Public Health: 

7
• 

• 

• 

Rural communities differ significantly across and within geographic regions, 

necessitating local solutions to local challenges that include economic factors,

demographic makeup, population density, terrain, and distance from urban areas, 

community resources, and public health presence. 

The vast majority of rural public health workers have little or no specialty 

training in public health, and an additional barrier to needed education and 

training is the inability to take time away from often understaffed local health 

departments. 

There is a need for surveillance systems to be sensitive enough to address 

small numbers issues and broad enough to track emerging infections. The 

systems should have the capability of communicating across county and state 

boundaries. 

Technology, which has been instrumental in providing access to information 

and training in most other areas, is lacking in rural areas. As reported by the National 

Advisory Committee on Rural Health, fewer than half of public health agencies have 

adequate communications and infrastructures. 

Medically underserved communities are areas in which residents have a 

shortage of personal health services. These communities may be in rural or urban 

settings. There may be a shortage of health professionals and/or economic, cultural, 

or linguistic barriers to healthcare. Access to care is an issue critical to improving 

health status throughout rural America. Access to specialty care is an issue for both 

provider and beneficiary in rural and medically underserved communities. 

The Institute of Medicine is conducting a study on “The Future of Rural 

Healthcare,” which is anticipated to include the development of “a conceptual 

framework for a core set of services and the essential infrastructure necessary to 

deliver those services to rural communities.” When completed, this study could 

provide a basis for focusing federal and industry efforts to provide affordable options 

for providers in rural and medically underserved communities. 

8
IV. Rural Health and Medically Underserved Target 

Architecture – “Blueprint” or “Roadmap” 

Key to understanding and developing approaches and information technology 

strategies for improving healthcare delivery in rural and medically underserved 

communities is having a “blueprint” or “roadmap.” The blueprint defines the 

business of healthcare delivery in rural and medically underserved communities 

today and at some point in the future. It highlights where supporting information 

technologies are required and what data, security, and communication standards 

should be adopted. The blueprint also serves as a common point of reference from

which national, regional, state, and local authorities and the private sector can 

develop a “bridge” or plan to get from today to the future. Likewise, it supports 

fundamentally sound information technology decisions by minimizing the potential 

for duplication of effort and reducing costly system changes as needs evolve. 

The Federal CIO Council defines the blueprint as an enterprise architecture 

(EA), “a strategic information asset base, which defines the business mission, the 

information necessary to perform the mission, the technologies necessary to perform

the mission, and the transitional processes for implementing new technologies in 

response to the changing mission needs.” The key components of the EA are: 

• Accurate representation of the business environment, strategy, and critical 

success factors; 

• Comprehensive documentation of business units and key processes; 

• Views of the systems and data that support these processes; and 

• A set of technology standards that define what technologies and products 

are approved for use within an organization, complemented by 

prescriptive, enterprise-wide guidelines on how to best apply these 

technology standards in creating business applications. 

The Office of Management and Budget and the General Accounting Office have 

long advocated that effective use of an EA is a recognized hallmark of successful 

public and private organizations. DoD fully embraces the need for enterprise 

architecture(s) and is using them to modernize antiquated business processes and 

promote interoperability and information management. Relevant aspects of the 

DoD/Military Health System enterprise architecture can serve as a model for local or 

regional architecture efforts in communities and between private sector healthcare 

providers, and further the objectives of the National Health Information 

Infrastructure initiative. 

9
An EA fosters interoperability, knowledge dissemination, enhances information 

security, collaboration of “best practices,” and identification of healthcare 

information technology needs across the rural and medically underserved landscape. 

V. Interoperability and Common Standards 

A. Interoperability—Data Exchange 

The VA and DoD have made significant progress with development of 

electronic data exchanges. Within the Departments, the focus of this work has been 

on the creation of a seamless transition for those military service members who 

separate from service and seek care from the VA. VA and DoD believe that their 

model of cooperation and joint development work can serve as a model among 

federal agencies and for national cooperation. Interoperability initiatives cosponsored by the VA and DoD are described below. 

1. Federal Health Information Exchange 

In April 2002, the Departments adopted a strategy to develop interoperable 

electronic medical records by FY 2005. The plan provides for the joint adoption of 

standards, the development of interoperable data repositories, and joint or 

collaborative development of interoperable health information applications. 

As part of this plan, the Departments have worked on and are planning a series 

of progressive data exchange initiatives. In May 2002, the Departments began the 

electronic transfer of clinical information from DoD to VA on separated or retired 

service members. As of June 2004, DoD has transferred clinical information on over 

2.27 million prior service members to the VA through the Federal Health Information 

Exchange (FHIE). FHIE continues to transfer clinical information from the DoD 

Composite Healthcare System (CHCS) to the FHIE Data Repository, where it is 

available for viewing by VA clinicians using the VA’s Computerized Patient Record 

System and claims adjudicators from the Veterans Benefit Administration using the 

Compensation and Pension Records Interchange system. DoD has transmitted data 

on over 2.27 million separated service members containing information on: 

Demographic data (name, patient, category, social security number, date of 

birth, sex, race, religion, address, marital status, and primary language); 

o 

o 

o 

Laboratory results (clinical chemistry, blood bank information, microbiology, 

surgical pathology, and cytology); 

Outpatient pharmacy data (Military Treatment Facilities [MTF]), DoD mailorder pharmacy, and retail pharmacy data); 

10
o Allergy information; 

o 

o 

o 

o 

o 

Radiology results; 

Discharge summaries (patient history, diagnosis, and procedures); 

Consult reports (referring physician and physical findings); 

Admission, discharge, and transfer information (demographic data, admission 

data, and discharge data); and 

Standard Ambulatory Data Record (SADR) (ICD-9 diagnosis and CPT-4 

procedure codes, treatment provider, encounter date and time, and clinical 

service). 

The Departments are presently engaged in work that will support a real-time, bidirectional exchange of limited data sets between DoD and VA on shared patients. 

The CHCS/VistA Data Sharing Interface (DSI) work includes plans to re-use jointly 

developed DoD/VA infrastructure, numerous information technology (IT) 

investments, VA/DoD test facilities, and existing personnel resources to quickly

create a real-time, bi-directional interface to permit a MTF to share clinical data 

capable of computational actions with its associated VA medical facility. 

2. Clinical/Health Data Repository

Beyond bi-directional data exchange in present systems, the Departments also 

are developing an interface between the DoD Clinical Data Repository and the VA 

Health Data Repository. This initiative, known as “CHDR,” will support the bidirectional exchange of health data. Phase I of this effort is the acquisition of a 

pharmacy prototype that will demonstrate the bi-directional exchange of computable 

outpatient pharmacy data, allergy information, and patient demographics in a 

laboratory environment by October 2004. The prototype is under development and 

on schedule. Phase II is the further development of the CHDR interface to enable its 

use in clinical settings. Using clinical decision support applications, providers in 

both departments will be able to access and use relevant clinical data to make 

important medical decisions for their patients, regardless of whether that information 

resides in the VA or the DoD system. 

3. Laboratory Data Sharing Interoperability

The Departments are also engaged in an initiative that allows DoD or VA to use 

the other Department as a reference laboratory. The Laboratory Data Sharing 

Initiative (LDSI) facilitates the electronic transfer/sharing of laboratory order entry 

and results retrieval between DoD, VA, and commercial reference laboratories. 

LDSI enables either VA or DoD to generate an order in their system, send it 

electronically to the other Department, and receive the results electronically. This 

11
eliminates re-keying of data and contributes to patient safety. Successful testing has 

been completed in Hawaii, and LDSI is being deployed to DoD and selected joint 

venture sites. In the future, LDSI will be enhanced to include additional types of 

laboratory tests (e.g., microbiology and anatomic pathology). 

4. Consolidated Mail Outpatient Pharmacy

DoD and VA conducted tests at three locations to determine the impact of DoD 

shifting some of its pharmacy refill workload to a VA regional Consolidated Mail 

Outpatient Pharmacy (CMOP). The pilot test ran for one year and received 

favorable feedback from both beneficiaries and MTF staff. Many beneficiaries 

indicated a willingness to use CMOP. In FY04 the continuation of the CMOP 

program is at the discretion of the MTF commander at each of the pilot sites. 

5. Centralized Credentials Quality Assurance Systems/VetPro 

DoD and VA are exploring the merits of electronically sharing credentialing 

information. The purpose is to improve the initial process for provider credentialing. 

When a credentialed provider in either DoD or VA requests credentials at a facility in 

the other Department, the Credentialler electronically requests the file from the 

Department where the provider is currently credentialed. Shared data sets (~ 60 data 

elements) are sent electronically to prepopulate the provider’s new file. The data is 

validated and the Department sends a message stating either that all data was 

accepted or that any discrepancies exist including changes made by the provider. 

The need for the provider to write the same information twice is eliminated. The 

pilot at three sites was concluded in June 2004. CCQAS/VetPro is now being 

implemented in the San Antonio area. 

6. Federal Health Architecture Electronic Health Record

Initiative 

In addition, DoD and VA co-chair the Department of Health and Human 

Services sponsored Federal Health Architecture, Electronic Health Records Working 

Group. The working group is responsible for recommending a target healthcare 

services electronic health record architecture. This work is an eGov initiative in 

support of the President’s Management Agenda. 

The by-products of much of the work the Departments have done can be shared 

with regional, state, and local entities in knowledge transfer and lessons learned. The 

Departments currently share this information through involvement at the national and 

12
local levels in organizations such as the Healthcare Information and Management 

Systems Society and through forums such as the annual “Toward an Electronic 

Patient Record” conference. 

 

B. Data, Security, Technical, and Communication Standards 

In addition to the development of large-scale electronic data exchange systems, 

DoD and VA have achieved the common adoption of an initial set of standards 

through the Consolidated Health Informatics (CHI) initiative (See Table 1). DoD 

and VA are lead partners in the CHI project, one of the 24 eGov initiatives 

supporting the President’s Management Agenda. The goal of the CHI initiative is to 

establish federal health information interoperability standards as the basis for 

electronic health data transfer in federal health activities and projects. Appendix B 

outlines those standards that are relevant to information sharing. DoD and VA have 

established an initial joint strategy for data standards that focuses on maximizing the 

utilization of the CHI standards in future systems development and acquisitions and 

influencing Standards Development Organizations (SDOs) in further standards work. 

Standardized data ensures that the definition of a data element is the same to all 

users. It is critical to the exchange of health information. This federal government 

effort has the potential to catalyze industry to adopt common terminologies and 

standards that will lead to increased utilization of the electronic medical record and 

enable the exchange of health information. 

Table 1. Approved and Adopted CHI Standards 

HL7 2.4 and 

higher XML 

Adopt Health Level 7 messaging standards to ensure that each federal agency can share information 

that will improve coordinated care for patients such as entries of orders, scheduling appointments and 

tests and better coordination of the admittance, discharge and transfer of patients. 

Adopt Health Level & vocabulary standards for demographic information, units of measure,

immunizations, and clinical encounter and HL7 Clinical Document Architecture standard for text base 

reports. 

NCDCP 

Scripts 

Adopt certain National Council on Prescription Drug Programs (NCDCP) standards for ordering drugs 

from retail pharmacies to standardize information between healthcare providers and the pharmacies.

These standards already have been adopted under the Health Insurance Portability and Accountability 

Act (HIPAA) of 1996, and today's announcement will make sure that parts of the three federal 

departments that aren't covered by HIPAA will also use the same standards. 

IEEE1073 Adopt the Institute of Electrical and Electronics Engineers 1073 (IEEE1073) series of standards that 

allow for healthcare providers to plug medical devices into information and computer systems that 

allow healthcare providers to monitor information from an ICU or through telehealth services on 

Indian reservations, and in other circumstances. 

LOINC Adopt laboratory Logical Observation Identifier Name Codes (LOINC) to standardize the electronic 

exchange of clinical laboratory results. 

DICOM Adopt Digital Imaging Communications in Medicine (DICOM) standards that enable images and 

associated diagnostic information to be retrieved and transferred from various manufacturers' devices as 

well as medical staff workstations. 

SNOMED -

CT 

The College of American Pathologists Systematized Nomenclature Medicine Clinical Terms (SNOMEDCT) for laboratory results contents, non-laboratory interventions and procedures, anatomy, diagnosis 

and problems, and nursing. 

HIPAA The Health Insurance Portability and Accountability (HIPAA) transactions and code sets for electronic 

exchange of health related information to perform billing and administrative functions. These are the 

same standards now required under HIPAA for health plans, health clearinghouses and those healthcare 

13
providers who engage in certain electronic transactions.

Federal 

Terminologies 

A set of federal terminologies related to medications, including the Food and Drug Administration’s 

names and codes for ingredients, manufactured dosage forms, drug products and medication packages 

the National Library of Medicine’s RxNORM for describing clinical drugs and the Veterans 

Administration’s National Drug File Reference Terminology (NDF-RT) for specific drug classifications. 

HUGN The Human Gene Nomenclature (HUGN) for exchanging information regarding the role of genes in 

biomedical research in the federal sector.

EPA 

Substance 

Abuse 

Registry 

System 

The Environmental Protection Agency’s Substance Registry System for non-medicinal chemicals of 

importance to healthcare . 

DoD and VA work with the American National Standards Institute’s (ANSI) 

and Healthcare Informatics Standards Board to influence the adoption and 

implementation of nationally and internationally approved standards. DoD 

recognizes the value of participation with Health Level Seven (HL7), an ANSI 

accredited standards developer (ASD) that has distinguished itself as a leading SDO 

in healthcare. In addition to its historical prevalent messaging standards, HL7 has 

provided a forum for hosting and collaborating with several other SDOs with 

healthcare interests, such as IEEE. 

In addition, DoD and VA also participate in the National Health Information 

Infrastructure (NHII) Taskforce. The focus of the taskforce is on activities to help 

the healthcare industry create and adopt a national health information infrastructure. 

The purpose is to create a comprehensive knowledge-based network of interoperable 

systems capable of providing information for sound decision support available 

anywhere and at any time it is needed. The benefits of NHII would be: 

• Improved patient safety; 

• Improved quality of care; 

• Effectively shared decision support; 

• Better understanding of healthcare costs; 

• Monitored and protected public health; and 

• Better informed healthcare consumers. 

Through the above-mentioned areas and participation in other varied

professional and standards development organizations, DoD and VA seek to 

influence local, state, and national agencies as well as private industry to cooperate in 

adopting and implementing common standards. 

C. Infrastructure Considerations 

The ability to securely exchange interoperable data that is understood the 

same by all users is predicated upon having a method of capturing, storing, and 

14
securely transmitting and receiving data to and from somewhere else. The 

components to achieve this include computers, databases, servers, communication 

networks, Internet connectivity, and security firewalls; which together are termed 

information technology infrastructure. Figure 1 illustrates the components of 

infrastructure that must be in place to successfully exchange information. 

15
Figure 1. Information Technology Infrastructure Components 

Remote Users 

Computing 

Infrastructure 

Security 

Devices 

Security 

Local Users

Local Area Network (Communications) 

Wide Area 

Network

(Communications 

Internet) 

Devices

Local Area Network 

Local Users

DoD has a wealth of experience in developing and implementing common and 

unique infrastructure solutions that provide the foundation for all information 

exchange. The robustness and availability of this foundation is an absolute measure 

of success when implementing software applications. This experience can be shared 

with the private sector. 

VI. DoD Health Information Technologies for Use in 

Different Environments 

DoD has successfully used various types of health information technologies in 

different environments for different purposes. Whether these technologies are 

appropriate, affordable, and meet the needs of the rural and medically underserved 

communities must be determined based on the needs of rural and medically 

underserved communities and the target blueprint or architecture. The lessons

learned and knowledge gained from the DoD experiences should continue to be 

shared with the private sector and local/state organizations to help guide efforts in 

these areas. 

The intent of this section is to describe scenarios in which health information 

technologies have been used successfully by DoD in circumstances that may also be 

applicable to rural or underserved communities. These scenarios may be used as a 

basis for developing a blueprint or architecture for these communities. The scenarios 

16
Referral Hospital 

Encounter Info

State/County Health 

Dept 

-Medical Surveillance 

vary from use of basic health technology configurations to more complex telehealth 

technologies. Regardless of complexity, successful implementation of health 

information technology and exchange of data is often predicated upon: (a) user 

acceptance, (b) use of common standards, (c) quality of data, (d) flexible data 

structures, (e) a secure communications and computing infrastructure, (f) adequate 

training, and (g) thoughtful attention to change management. 

A. Mobile Healthcare Provider Setting 

DoD currently uses the mobile workstation model called the Composite Health 

Care System II (Theater), as depicted in Figure 2. This technology allows mobile 

military providers in remote areas to document healthcare (to include clinical order 

documentation) with a stand-alone notebook PC at the point of care. Patient data 

may be stored on the PC, downloaded from the device, and either transmitted to a 

mainframe database using encrypted technologies, or stored on a disk or storage

device for transport with the individual. As patients move through the various levels 

of care from a small, forward-deployed unit in a combat setting back through 

successively larger and more sophisticated levels of care, their health information is 

accessible to providers at the receiving facilities, regardless of how remotely located 

from the original point of collection. Aggregate data from multiple patient 

encounters is used to monitor untoward medical incidents in a given area or 

population and report to appropriate leadership. The isolated conditions encountered 

in wartime or other overseas peacekeeping missions can be compared to the 

conditions in some rural healthcare environments and the need to transport the data to 

other facilities or providers may be applicable to situations such as the case of 

migrant workers. 

Figure 2. Mobile Workstation Model 

B. Small Family Practice Clinic Setting 

17
The small family practice clinic health information configuration supports a 

group of co-located providers with the ability to document and share healthcare 

encounter information, as illustrated in Figure 3. This model provides the same basic 

capabilities as the Mobile Workstation Model. It provides the ability to have a small 

database in the clinic where patient health record information can be accessed by any 

provider, thus providing continuity of care. Select data fields can be sorted and 

aggregated for population health management or medical surveillance. A local area 

network (LAN) would be required to support this model. The DoD CHCS II-T or the 

NT version, which provides limited ancillary order entry and results retrieval 

capabilities would apply to this environment as well. 

Figure 3. Small Family Practice Clinic Model 

 

-Complete

Encounter 

Synch

Desktop

Synch

 Desktop 

-Complete

Encounter

Referral Hospital

Encounter Info 

State/County Health Dept

-Medical Surveillance 

C. Large Clinics and Smaller Hospitals 

Larger clinics and smaller hospitals would benefit from an Electronic Health 

Record that provides full order entry, results retrieval, and ancillary workflow 

support (to include pharmacy, radiology, laboratory services, and alerts for drugallergy and drug-drug interactions) such as in the DoD clinical system suite of 

capabilities. This capability has been successfully transferred to the United States 

Coast Guard. 

A DoD capability that may have application in remote or rural areas is called 

TRANSCOM Regulating and Command and Control Evacuation System

(TRAC2ES). This system provides visibility on bed status at local hospitals in a 

geographical area. A health information technology such as this would support better 

National Disaster Medical System reporting and give Homeland Defense greater 

visibility of hospital beds for regulating in disaster response situations. 

18
D. TeleHealth Used for Long Distance Consultations and 

Distance Learning 

Telehealth applications have been successfully utilized to extend medical care 

to remote areas of the world, disaster assistance teams, and ships at sea. Telehealth is 

defined as the use of electronic information and telecommunications technologies to 

support long-distance clinical healthcare, patient and professional health-related 

education, and public health and health administration. DoD has several successful 

joint ventures with the VA using telehealth technologies, as outlined in Appendix C. 

For the DoD, telehealth provides medical support to service members in combat 

situations. The active-duty force has a special need for telehealth capabilities to 

support readiness missions in which medical care may not be readily available. 

Troops are often isolated and not able to access the level of care required for illness 

or injury. Use of telehealth puts a “virtual” medical component in the field, 

potentially saving life and limb. In less severe cases, telehealth may reduce the 

number of troops requiring evacuation for what would normally be routine medical 

care. Similar situations exist in rural and underserved environments, which could 

benefit from the use of telehealth. Appendix D provides a varied and impressive 

view of the benefits of Telehealth. 

VII. Contracting Considerations 

DoD has a wealth of experience in developing healthcare information 

technology acquisition strategies, performance based contracts, negotiated volume 

discounts, and contract management. Template contract language has been 

developed to support the DoD community in expediting contract awards and laying 

the foundation for interoperability. This information can be made available to the 

private sector. 

19
VIII. Summary of Approaches and Knowledge Transfer 

The following summarizes the DoD recommended approaches in collaboration 

with ONCHIT to make health information systems available as an affordable option 

for providers in rural and medically underserved communities. A number of these 

approaches focus on the transfer of knowledge gained from the experiences of DoD 

that can serve as a foundation for planning in support healthcare delivery in rural and 

medically underserved populations. 

• DoD will collaborate and coordinate recommendations with ONCHIT in support 

of the development of a Strategic Plan. 

• DoD will communicate, encourage and incentivize industry business partners to 

actively support the President’s agenda. 

• The National Governors Association (NGA) or a similar organization should 

establish a consortium of local and state authorities to develop a blueprint or 

roadmap targeted at healthcare delivery in rural and medically underserved 

communities – this blueprint will serve as a common business reference point 

from which information technology investment decisions can be made. 

o DoD should share with ONCHIT their health enterprise architecture and 

lessons learned with the NGA consortium, local and state governments, 

and private industry. 

• DoD and VA should continue to aggressively participate with Standard 

Development Organizations (SDOs) in the development of national health data, 

technical, security, and communication standards, which foster interoperability 

and data exchange. 

• DoD and VA should continue to work with professional organizations such as 

Health Information Management System Society (HIMSS), American Medical 

Association (AMA), and support initiatives such as National Health Information 

Infrastructure (NHII) to facilitate the adoption and implementation of standards. 

• DoD and VA should continue to share with the private sector experiences and 

lessons learned from the many ongoing health data exchange initiatives. 

• Working with other federal agencies and organizations, DoD should draft 

templates of standard contract language for use nationally, which encourages 

20
industry to produce products and services that are scalable and applicable to the 

rural and underserved communities. 

o DoD will develop acquisition selection criteria which favorably consider those 

companies who agree to provide products and services that are applicable to 

targeted communities such as rural and underserved. 

• DoD recommends that the federal government establish regional or national 

contracting and acquisition centers of excellence to strengthen purchasing power 

(e.g. bulk buys) and sharing of contracting language and lessons learned. 

• DoD and VA should share electronically based educational programs, as in 

Appendix C, that serve to extend the use of professionals and paraprofessionals in 

remote areas and assist them in staying current on medically related topics. 

• In coordination with ONCHIT, DoD should share lessons learned and clinical 

practice templates in various forums with national, regional, state and local 

authorities and the private sector on such topics as: 

o Application of health information technologies in remote sites: 

o Management of information technologies in remote sites; 

o Implementing privacy and security measures; 

o Business process reengineering; 

o Unique infrastructure solutions; 

o Application of health standards in HIT; 

o Change management; and 

o Implementation challenges. 

• ONCHIT, with input from DoD and VA, should lead federal efforts to develop 

and implement an Electronic Health Record and common business rules (e.g., 

CHCS II); demonstrating a bi-directional exchange of health information in a 

secure manner and in keeping with applicable privacy regulations. 

• DoD should develop and implement the use of personal health records (e.g., 

TRICARE Online), demonstrating opportunities to educate providers and 

beneficiaries. 

21
IX. Considerations and Barriers 

• Lack of a common health enterprise architecture for rural and medically 

underserved communities; 

• Lack of communication and computing infrastructure; 

• Incomplete standards to support data exchange; 

• Lack of centralized funding/disparate funding streams across federal 

agencies; 

• Lack of incentives for the private sector and managed care organizations to 

provide solutions; and 

• Lack of national, state and local venues for knowledge transfer and sharing 

of lessons learned. 

X. Summary 

As two of the largest healthcare organizations in the nation, DoD and VA serve 

as catalysts for changing how healthcare is delivered in the future specifically as it 

relates to the use of health information technologies to improve access, healthcare 

delivery, population health management and patient safety. The health industry, to 

include rural and medically underserved communities, can benefit from the 

innovation, testing, standards development, health architectures, knowledge, and 

experience of the DoD and VA. Rural and medically underserved communities have 

unique health challenges with limited human and investment capital, which requires 

the attention of national, state, and local leaders. It is imperative that these 

challenges are articulated in a common framework or architecture so that available 

resources are invested judiciously and technical solutions provide the greatest 

flexibility and capabilities to meet future needs. DoD will actively work with the 

Department of Health and Human Services, specifically the ONCHIT, as they 

execute the mission as defined in the President’s executive order. 

22
XI. Appendices 

APPENDIX A 

DEFINITIONS 

Medically Underserved Areas (MUAs) may be a whole county or a group of 

contiguous counties, a group of county or civil divisions or a group of urban 

census tracts in which residents have a shortage of personal health services. 

Health Professional Shortage Areas (HPSAs) may have shortages of 

primary medical care, dental or mental health providers and may be urban or 

rural areas, population groups or medical or other public facilities. 

 Medically Underserved Populations (MUPs) may include groups of 

persons who face economic, cultural or linguistic barriers to healthcare. 

23
APPENDIX B 

TARGET DoD STANDARDS PROFILE 

Standards Relevant to Information Sharing 

Category/Sub-category Service Area Standards 

Information Standards 

Message Format

Clinical Information Electronic 

Data Interchange (EDI) 

HL7 v2.4 (XML encoding preferred) 

Medical EDI ANSI ASC X12N 270, 271, 276, 277, 278, 820, 834, 835, 837 

FIPS Pub 161-2

NCPDP Telecommunication Standard Implementation Guide v5.1

HL7 v2.4 (XML encoding preferred) 

Medical Still-Imagery EDI DICOM v3.0 

JPEG 2000 

Data Representation Standards 

Clinical Data 

Representation 

Drug Codes NDC

Lab and Clinical Observation 

Codes 

LOINC 

Mental Disorder Codes DSM-IV 

Multiaxial Medical

Nomenclature 

SNOMED, SNOMED-RT 

Outpatient Procedure CPT-4

Patient Diagnosis ICD-9-CM

Dental Codes CDT-4 

Ancillary Services Reporting 

and Claims Processing 

HCPCS 

Revenue Codes and 

Workload Weights 

RBRVS 

24
Standards Relevant to Information Sharing 

Category/Sub-category Service Area Standards 

Information Modeling and 

Metadata 

Object and Data Modeling FIPS Pub 184 (IDEF1X) 

OMG UML v1.4

OMG XMI 

Security Standards 

Authentication FIPS Pub 83, 112 

IETF RFC 1510, 2138, 2289, 2402, 2633 

ISO/IEC 7816 Parts 1-10 

Open Group C311 

Accountability ISO/IEC 10164-8 

Data Integrity and Nonrepudiation FIPS Pub 180-1, 186-2 

IETF RFC 2246, 2402, 2406, 2633 

IEEE 802.10 

ITU-T X.509 (2000)/ISO/IEC 9594-8:2001 

IETF RFC 2459

Confidentiality FIPS Pub 46-3, 74 , 140-2 , 185, 186-2 

IETF RFC 2420, 2559, 2633 

ITU-T X.509 (2000)/ISO/IEC 9594-8:2001 

IETF RFC 2459

Certification ISO/IEC 15408

FIPS Pub 140-2

Security Management ISO/IEC 10164-8 

Technical Standards 

Communications

Collaborative

Communications 

ITU-T.120, T.122, T.124, T.125 

Directory Services IETF RFC 1034, 1035 (DNS) 

IETF RFC 1777 (LDAP) 

ITU-T X.500 

Internet Transport Services IETF RFC 791, 793, 919, 922, 950, 959, 1112 (TCP/IP) 

IETF RFC 2131 (DHCP) 

IETF RFC 792 (ICMP) 

File Transfer IETF RFC 959, 2228 (FTP) 

Electronic Mail IETF RFC 821, 1869, 1870 (SMTP) 

Video Teleconferencing ITU-T H.221, H.230, H.242, H.243, H.244, H.261, H.263, H.320, H.323, 

G.711, G.722, G.728, T.120, T.122, T.124, T.125

Wireless IEEE 802.11a, 802.11b 

25
Standards Relevant to Information Sharing 

Category/Sub-category Service Area Standards 

Ethernet Standards ISO/IEC 8802-3 (10-Base-T, Ethernet) 

IEEE 802.3u (100-Base-T, Fast Ethernet) 

IEEE 802.3ab (1000-Base-T, Gigabit Ethernet) 

Object Management Services OMG CORBA v2.3.1 

W3C SOAP 

Web File Sharing IETF RFC 2616 (HTTP) 

ANSI/ISO/IEC 9636 series (CGI) 

Information Processing 

Document Distribution Format MS Word (.doc) 

Portable Document Format (.pdf) 

Rich Text Format (.rtf)

Data Management Services ISO/IEC 9075-3

Graphics Data Interchange GIF 

JPEG File Interchange Format v1.02 

Video Compression ISO/IEC 11172-, 2, 3 (MPEG1) 

ISO/IEC 13818 series (MPEG2) 

Document Interchange W3C HTML, XML 

Graphics Services ISO/IEC 8632-1, 3, 4 (CGM) 

26
APPENDIX C 

VA/DoD TELEHEALTH PROJECTS 

• VA-DoD Imaging Subgroup: This working group was established under the joint 

Military Health System (MHS) and VA Clinical Data Repository-Health Data 

Repository (CHDR) Working Integrated Product Team to develop a strategy for 

sharing medical and dental digital images associated with beneficiary electronic 

healthcare records. Comprised of functional and technical experts from each 

agency, the Imaging Subgroup has recognized that interoperability of digital 

images depends on utilization of a common standard called Digital Imaging 

Communications in Medicine (DICOM). The group has drafted a joint document 

identifying the DICOM conformance requirements that image acquisition vendors 

must meet in order to be recommended for purchase. Once approved for release 

to the field, this collaborative statement will provide greater influence on the 

marketplace than either agency could achieve alone. The benefit will be 

improved interoperability between DoD and VA digital imaging information 

systems. 

• Teleradiology: 

- The Army’s Southeast Regional Medical Command is working with the VA to 

support ongoing local initiatives specific to Teleradiology between the 

following: 

○ Eisenhower Army Medical Center and the Augusta VA Hospital in 

Georgia, 

○ Ft. Campbell and the VA in Kentucky, and 

○ Ft. Jackson and the Columbia SC, VA (specific to CT Scans whereby Ft. 

Jackson sends images over a 100MB fiber link to the VA) 

- The “I-25 Corridor Working Group” has begun connecting together the USAF 

Academy Hospital (USAFA), clinics at Buckley, Schriever, Peterson, 

Malmstrom, and FE Warren AFBs, the hospital at Ft. Carson, VA medical 

clinics in La Junta and Pueblo CO, and VA Medical Centers in Denver CO

and Cheyenne WY, to enable exchanging digital radiographs and MRIs, thus 

allowing workload sharing and rapid provision of remote specialist 

interpretation. VA Denver, USAFA, Peterson, and Carson have already 

starting exchanging images. 

27
- Sacramento VA Medical Center (old Mather AFB, CA) sends Emergency 

Room after-hours and weekend x-ray and CT images to Travis AFB’s David 

Grant Medical Center (DGMC) over a point-to-point T1 line using dynamic 

compression technology. Radiology residents at DGMC make preliminary 

review and fax results back to the VA. Final interpretations and dictations are 

performed by VA radiologists. This helps maintain workload requirements 

for Travis radiology residency program and improves quality of life for 

understaffed VA Medical and Regional Office Center (VAMC) radiologists 

who have limited on-call responsibilities. 

- Madigan Army Medical Center is planning Teleradiology with the Seattle VA 

once both sites have updated their systems and have established connectivity 

• Telepsychiatry: Weed Army Community Hospital (Ft. Irwin, CA) is working 

with the Los Angeles VA Regional Office to establish a VA/DoD sharing 

agreement to perform Compensation and Pension examinations, utilizing 

telemedicine for psychiatric examinations on persons separating/retiring at Fort 

Irwin who require such evaluation. 

• Hawaii Integrated Federal Healthcare Partnership: The Pacific Telehealth and 

Technology Hui was established in 1999 as a joint partnership of the VAMC 

Honolulu and Tripler Army Medical Center (TAMC) to manage joint Telehealth 

projects involving research, development, prototype, evaluation and technology 

transfer. These efforts include: 

- Two projects developed under a joint initiative with the Joslin Diabetes 

Center, one of the world’s leading research centers for diabetes. It is further 

described below in Case Management. The first project, the Joslin Vision 

Network (JVN), provides a platform for assessing the severity of diabetic 

retinopathy using a highly sophisticated digital camera to capture and transmit 

an image of the retina to a reading station for remote evaluation. The second, 

the joint Hui-Joslin initiative called the Holopono program, demonstrates the 

use of Internet technology to manage follow-up care for patients with diabetes. 

- A project that permits electronic transmission of pharmacy orders between 

TAMC and VAMC Honolulu for dispensing. This interface allows pharmacy 

orders written at the DoD facility to be transmitted electronically and filled at 

the VA pharmacy. 

- Janus, a project that allows DoD providers to retrieve patient data from the 

VA’s VistA patient record system. It provides a single Graphical User 

Interface (GUI) front end that links to a web application to pull data from 

VistA to provide end-users on TAMC’s Composite Healthcare System 

(CHCS) with VistA patient record information. 

28
• Alaska Federal Healthcare Access Network: This initiative of the Alaska Federal 

Healthcare Partnership is comprised of DoD, VA, Indian Health Service (IHS), 

the US Coast Guard and other state and federal agencies. Its goal is to use new 

telecommunications and telemedicine technology to extend and improve access to 

healthcare service and information for over 200,000 federal beneficiaries. The 

project has linked 235 federal and state healthcare sites into a statewide 

telemedicine system. Using state-of-the-art technology and equipment, member 

organizations have begun to send medical images, health information, and voice 

data to regional hospitals for remote diagnosis and consulting. 

• Case Management (Diabetes): The Joslin Vision Network (JVN) is a 

telemedicine application focused on increasing access of diabetic patients into 

appropriate eye care and represents a collaborative effort between the DoD, VA

and Joslin Diabetes Center in Boston. The original proof-of-concept JVN system 

has evolved into a second-generation system using non-proprietary Microsoft 

hardware and software, which leverages the established Patient Archiving and 

Communications System infrastructure and implements the Comprehensive 

Diabetes Management Program (CDMP) proposed in the Chronic Care Model 

developed by Edward Wagner, M.D. Its six components are: (1) Coordination 

with community resources (2) Strategic commitment of the organization (3) 

Support of patient self-management (4) Redesign of delivery system (5) Clinical 

decision support and (6) Clinical information systems. The JVN eye care system: 

- Is currently deployed in 32 active remote imaging sites with six established 

and certified reading centers distributed across ten different states from 

Hawaii to New England, 

- Represents participating sites associated with the DoD, the Veterans Health 

Affairs and the IHS, 

- Has allowed access to over 12,000 patients into the JVN eye care system since 

September 2001, 

- JVN CDMP application is currently live at the Joslin Diabetes Center and 

Walter Reed Army Medical Center, 

- Provides significant opportunity, when leveraged with deployed 

teleconsultation systems, to realize substantial cost savings for treating chronic 

disease. 

29
• e-Learning: The Adult Nurse Practitioner Post Master’s Program is a 

collaborative effort between the VA and the Graduate School of School of 

Nursing, Uniformed Services University for the Health Sciences (USUHS), which 

provides a Nurse Practitioner Distance Learning educational curriculum for VA 

and DoD nurses. It demonstrated that students and teachers, separated by 

geographic distance, can participate fully in an effective and meaningful 

educational process using electronic technology for communication. USUHS 

enables distance learning in support of the doctoral Nursing Science program for 

DoD and VA nurses. USUHS is also in the process of building a distance 

learning component to their Master’s in Public Health program that could be 

utilized by DoD and VA providers. 

30
APPENDIX D 

BENEFITS OF TELEHEALTH 

The benefits of telehealth are varied and impressive. Though some are difficult to 

quantify as they are concerned with quality of care or military troop readiness, the 

following list highlights benefits that already have been demonstrated in a multitude 

of pilot projects throughout the world, not just in the military: 

• Biosurveillance, and thus Homeland Defense capabilities, are enhanced by 

providing data feeds from electronic and telephone triage systems and 

teleconsultations. 

• Travel costs associated with transportation to distant specialty providers is 

reduced. 

• Scarce medical specialty and sub-specialty resources can be leveraged beyond the 

“brick and mortar” construct of medical care. 

• On-duty time and medical readiness is increased as a result of reduction in time 

spent to obtain specialty medical care. 

• Access to care is enhanced, especially where travel distances represent a 

significant barrier. 

• Turnaround time for consultations is considerably faster (e.g. from 30 days to 72 

hours). 

• Unnecessary medical evacuations are reduced. 

• Health services in the home and community-based care locations are augmented. 

• Mortality and intensive-care bed days are reduced through utilization of electronic 

critical/intensive care monitoring (as shown in commercial studies). 

• Costs of emergency care and inpatient hospital stays are decreased through more 

effective case management utilizing electronic home-health monitoring systems. 

• For VA and DoD, the amount of specialty care provided to beneficiaries by the 

private sector is reduced, providing cost savings. 

• The quality of residency teaching via an e-Learning platform enables gathering of 

relevant specialty cases for review and dramatically enhances provider education. 

31

ATTACHMENT 4: 

Federal Health Information Technology Programs 

The Decade of Health Information Technology: 

Delivering Consumer-centric and Information-rich Health Care 

Framework for Strategic Action 

July 21, 2004 

Attachment 4 

Federal Health Information Technology Programs 

The following report was issued by the National Coordinator for 

Health Information Technology under direction of Executive Order 

13335, Incentives for the Use of Health Information Technology 

and Establishing the Position of the National Health Information 

Technology Coordinator, April 27, 2004. 
Attachment 4. Federal Health Information Technology Programs 

The Office of the National Coordinator for Health Information Technology (ONCHIT) is 

responsible for coordinating federal activities relating to health information technology. 

These covered health information technology activities are defined as any effort in the 

federal government that meets one or more of the following criteria: 

1. Efforts that use federal funds to design, develop, standardize, implement, 

maintain, operate, and/or enhance HIT (e.g., software, hardware or other 

technology) that is used inside or outside the federal government to deliver, 

monitor, improve, supply information to, interface with, or use information from a 

patient care encounter, including financial, clinical, or other information. 

2. Efforts that use federal funds for projects or programs that evaluate, research, 

study, or otherwise assess the use, benefit, cost, consequences, or other aspects of 

the HIT defined in #1. 

3. Efforts that use federal funds to educate, teach, train, or address human factors 

about or relating to the HIT described in #1. 

4. Policies, rules, reports, advisories, or other documents that describe, discuss, or 

influence the use of the HIT defined in #1. 

5. Partnerships, grants, contracts, initiatives, or awards between the federal 

government and/or its contractors with non-federal organizations, including state 

or local governments or agencies, private companies, or other entities that relate 

to HIT defined in #1. 

6. Knowledge management of the experiences gained from HIT implementation 

across large, distributed health care networks such as DoD, VA, and the IHS will 

be brought to a central, accessible point. 

Many different components of the federal government touch upon health care, so federal 

leadership in HIT needs to be focused and coordinated. While there is some integration 

of these efforts, until recently there has been neither a single voice for this effort nor a 

holistic set of goals for change. The National Coordinator for Health Information 

Technology has been given the responsibility for coordinating HIT efforts throughout the 

federal government. As part of the outreach effort, the programs, projects, and policies 

that involve HIT are being compiled 

According to the FHA initiative and budget documents submitted to the Office of 

Management and Budget, total federal spending on HIT was over $900 million in 

FY2004. A list of identified federal HIT programs follows. Federal HIT initiatives range 

from supporting research in advanced HIT (e.g., high-speed Internet, imaging, and 

bioinformatics) to the development and use of EHR systems. Overall, the compilation in 

the following table shows that the federal government has played an active role in the 

evolution and use of HIT, and further analysis of agency obligations and programmatic 

activities suggests that there is additional HIT spending within federal grants and other 

activities. The implementation of this strategy is an opportunity to comprehensively 

identify HIT spending activities, and to better enable collaboration that leverages these 

efforts. 

1 
Attachment 4. Federal Health Information Technology Programs 

VA provides to physicians, registered nurses, dentists, optometrists, podiatrists, nurse 

anesthetists, physician assistants, and other staff an EHR system known as VistA. The 

VA’s work on the evolution of this EHR and diagnostic imaging is leading the field. The 

VA first demonstrated the effectiveness of bar coding for improving patient safety in

hospital drug administration. This success contributed to the FDA’s development of 

regulation requiring bar codes on drug products. 

Another example of federal leadership is DoD’s Pharmacy Data Transaction Service 

(PDTS), which is linked to DoD’s EHR system. This utilizes a centralized data repository 

that records information about prescriptions filled for DoD beneficiaries through Military 

Treatment Facilities (MTFs), the civilian pharmacy network, and the TRICARE Mail 

Order Pharmacy program. PDTS enhances patient safety and quality of medical care by 

reducing the likelihood of adverse drug-to-drug interactions, duplicate drugs prescribed 

to treat the same condition, and the same drug obtained from multiple sources. This 

system has detected more than 117,000 potential Level 1 drug interactions over the last 

three years. 

Other innovative activities are under way in the federal government. DoD and VA utilize 

telehealth applications for radiology, mental health, dermatology, pathology, and dental; 

for provider/patient education interactions; and as provider extenders. IHS has had an 

electronic health information system for over 25 years. IHS is currently adapting an EHR 

to fit the special needs of its hospitals and clinics. CMS is developing programs to 

promote the adoption and effective use of HIT through the Doctors' Office Quality 

Information Technology (DOQ-IT) pilot project and the Medicare Care Management 

Performance demonstration. 

Standards adoption has been a core federal program. HHS has acquired the license to 

SNOMED CT©, a medical terminology, for use throughout the U.S. The VA and DoD 

are developing interoperable health information systems to support the seamless transfer 

of health information and continuity of services for beneficiaries. To accelerate progress 

within the government, HHS, DoD, and VA are lead partners in the CHI, one of the 24 eGov initiatives supporting the President’s Management Agenda. The goal of the CHI 

initiative is to establish federal health information interoperability standards as the basis 

for electronic health data transfer in federal health activities and projects, which will 

facilitate the adoption of these standards in products used in the private sector. These 

federal agencies also support the FHA effort to develop an interoperable and common 

architecture for HIT across agencies. 

Federal agencies are also stimulating formation of private sector health information 

exchange. AHRQ will spend $50 million in FY2004 on HIT research and demonstration 

projects aimed at improving the safety, quality, efficiency, and effectiveness of care. 

Using a portion of these resources, AHRQ will establish a Health Information 

Technology Resource Center that will provide technical assistance, expert HIT support, 

educational services, and other support to HHS grantees. AHRQ will also fund five statelevel HIT projects to support health information exchange across these communities. The 

Health Resources and Services Administrations is accelerating adoption and enabling 

2 
Attachment 4. Federal Health Information Technology Programs 

community health information exchange through several programs including Connecting 

Communities for Better Health, the BPHC Healthy Communities Access Program, and 

telehealth programs. 

The tools to ensure advances in population health and research are evolving. NIH is 

working to ensure the development of an infrastructure to support clinical research that 

will interface with community health information exchange networks. CDC is 

facilitating the implementation of a public health information infrastructure in a variety of 

fronts. This effort is already demonstrating results; the reporting times have dropped 

from an average of 30 days to 1-2 days. Work on and support for the U.S. Department of 

Homeland Security’s BioWatch and BioSense continues, solidifying the infrastructure

needed to detect and respond to emerging diseases and a bioterrorist event. Also, CDC is 

advancing the development of the Public Health Information Network (PHIN), which 

supports the broad range of public health activities, including interoperability with 

clinical care. It now includes the National Electronic Disease Surveillance System as a 

surveillance component, which promotes the use of standards to advance development of 

efficient, integrated, and interoperable surveillance systems at federal, state, and local 

levels. BioSense, among other things, fosters the use of standards-based clinical care 

data for the early detection, localization, and investigation of emerging health events. 

The federal government has also acted to develop tools to support personalized care for 

the consumer. This is being accomplished through Healthfinder and Medline Plus, access 

to clinical trial information; DoD’s TRICARE Online (TOL), the enterprise-wide, secure, 

Internet portal for use by all DoD beneficiaries, providers, and managers worldwide to 

access available health care services, benefits, and information; and VA’s My 

HealtheVet. 

3 
Attachment 4. Federal Health Information Technology Programs 

The following table represents a preliminary, non-exhaustive, list of federal (HHS, VA, 

and DoD) projects meeting these criteria. ONCHIT will compile a database of programs, 

projects, and policies from various sources. This information will be for planning, 

coordination, and knowledge transfer. 

Agency/ 

Organization Title of HIT Initiative Description of Activities

Department of Health and Human Services 

Assistant Secretary for Planning & Evaluation 

ASPE National Committee on Vital and

Health Statistics (NCVHS) 

Policy development and development of standards. 

ASPE National Health Information 

Infrastructure (NHII)

The NHII is an initiative to improve the effectiveness, efficiency, 

and overall quality of health and health care in the United States -- 

a comprehensive knowledge-based network of interoperable 

systems of clinical, public health, and personal health information

that would improve decision making by making health information 

available when and where it is needed. (NHII has been 

incorporated into ONCHIT.) 

ASPE EHRs in Post-Acute and LongTerm Care ASPE has contracted with the University of Colorado Health

Sciences Center to evaluate the current status of electronic health 

information systems (EHIS) and electronic health records (EHRs) 

in post-acute and long-term care (PAC/LTC) settings. The project 

team has reviewed literature, conducted telephone interviews, and

completed site visits to providers that have implemented

EHIS/EHRs in PAC/LTC. The project also contracted with Apelon 

to conduct a pilot study of the issues of conforming the nursing 

home minimum data set (MDS v.2) to CHI standards. 

ASPE Conforming the Nursing Home 

Minimum Data Set v.3 to CHIEndorsed Standards

ASPE and CMS will partner on a project to conform the MDS v.3

to CHI-endorsed standards. 

Office of the Chief Information Officer (CIO) 

Consolidated Health Informatics 

Initiative (CHI) 

The goal of CHI is to establish federal health information

interoperability standards as the basis for electronic health data 

transfer in all activities and projects and among all agencies and

departments. The first phase involved establishing a set of

existing clinical vocabularies and messaging standards enabling 

federal agencies to build interoperable federal health data systems.

 Federal Health Architecture (FHA) TheFHA program will define an overarching framework and

methodology that allows initiatives throughout several federal 

agencies to proceed coherently, establishing the target and 

standards for interoperability and communication that will unify 

the federal health community. The FHA will establish a 

government-wide road map to achieve the federal health

community's mission through optimal performance of its core

business processes within an efficient IT environment. 

Council on the Application of Health Information Technology (CAHIT) 

CAHIT Coordination HL7 balloting CAHIT staff coordinated the HHS engagement with regard to the

HL7 Electronic Health Record Special Interest Group. 

CAHIT EHR Acceleration Efforts CAHIT staff coordinated a series of planning meetings to best 

position pertinent departmental HIT activities (either current or

future) that hold the promise of accelerating EHR adoption. 

4 
Attachment 4. Federal Health Information Technology Programs 

Agency/ 

Organization Title of HIT Initiative Description of Activities

CAHIT CHI Standards CAHIT staff and membership, via council meetings, activities, and 

staff briefings ensured the universal integration of CHI standards 

in HHS agency activities and programs. 

Agency for Healthcare Research and Quality (AHRQ) 

AHRQ Transforming Healthcare Quality

Through Information Technology

(THQIT) 

THQIT is a series of three grant programs (RFAs) released in

FY04. The RFAs include the following: 1) demonstrating the 

value of HIT, 2) planning grants for future HIT implementations, 

and 3) providing HIT implementation grants for partnerships of 

three or more entities. 

AHRQ State and Regional Health IT

Demonstrations 

AHRQ recently issued a contract solicitation to establish and 

implement state and regional demonstrations of interoperable 

health information systems. In the Fall of 2004, AHRQ anticipates 

issuing up to five awards. 

AHRQ Health Information Technology

Resource Center 

The Health Information Technology Resource Center (HITRC)

will provide a state-of-the-art service center for grantees and

organizations that are engaged in health IT diffusion activities 

(e.g., research, diffusion, or adoption). 

AHRQ Coordination with CMS Medicare 

Care Management Performance 

(MCMP) Demonstration Project 

AHRQ will be supporting a five-year evaluation of CMS’s MCMP 

demonstration project to explore the integration of EHRs in the 

ambulatory environment. 

AHRQ Indian Health Service (IHS) - 

Resource and Patient Management

System (RPMS) 

AHRQ recently provided funding to the IHS to support needed 

enhancements to the IHS EHR. This investment will help to create 

a user-friendly data system that can provide community-specific 

health care data as well as track the health status of the patient 

population. 

AHRQ Patient Safety Health Care 

Information Technology Data 

Standards Program: Standards and 

Interoperability 

This work on health data standards, done in coordination with the 

ASPE, will focus of the following four areas: 1) voluntary industry 

clinical messaging and terminology standards, 2) national standard

nomenclature for drugs and biological products, 3) standards 

related to comprehensive clinical terminology, and 4)

nomenclature and research related to accelerating the adoption of 

interoperable HIT systems. 

AHRQ Evidence Based Practice Center 

(EPC) - Evaluation of the 

Evidence Regarding Select Health 

IT Functions 

AHRQ's EPC Program has embarked on a 13-month program to

explore and determine the evidence base associated with certain 

HIT functions. 

Centers for Medicare and Medicaid Services (CMS) 

CMS Doctors' Office Quality - 

Information Technology (DOQ-IT)

A special study to develop an approach to promoting adoption and

use of information technologies in the physician office and 

reporting of information to Quality Improvement Organizations

(QIOs). 

CMS VistA – Office her Modify / repackage VistA (the Veteran's Administration EHR

software) for the physician office setting. 

CMS Medicare Care Management

Performance Demonstration 

Establish a three-year, pay-for-performance pilot with physicians

to promote the adoption and effective use of HIT to improve the 

quality of patient care for chronically ill Medicare patients. CMS 

will offer financial incentives to physician offices that meet 

performance standards in delivery systems and outcomes. 

5 
Attachment 4. Federal Health Information Technology Programs 

Agency/ 

Organization Title of HIT Initiative Description of Activities

CMS Physician self-referral exception:

Phase II of physician self-referral 

regulations includes exception for 

community-wide health

information systems 

Removes the regulatory barrier to allow for the furnishing of

technology items or services to physicians to enable their 

participation in community-wide health information systems. 

CMS E-prescribing hearings to develop,

adopt, recognize, or modify initial 

e-prescribing standards. 

Pilot project to test initial 

standards. 

Participate in NCVHS hearings regarding e-prescribing standards 

in 2004 and 2005. Develop, adopt, recognize, or modify initial 

uniform standards not later than Sept. 1, 2005. During 2006

calendar year, conduct pilot project to test initial e-prescribing 

standards, unless the Secretary determines the industry has 

adequate experience with such standards. 

CMS EMR Focus Groups Pacific Consulting Group, under contract with CMS, will conduct 

12 focus groups of providers to identify the issues and barriers that

would prevent them from using electronic medical records, and 

suggestions they may have for addressing these issues. The focus 

groups will be organized as follows: three Part A, three Part B, 

three durable medical equipment (DME) providers, two rural 

providers, and one billing agent. Six of these focus groups will be

in person, while six will meet via conference call. Focus groups

are planned for the following cities: Boston or New York City, 

Florida or Atlanta, Chicago, Denver, San Francisco. 

CMS CMS Virtual Call Center The goal of CMS' Virtual Call Center is to improve beneficiary

telephone customer service through the implementation of various

initiatives for efficient and effective handling of all types of

inquiries. The first phase involves, among other things, 

improvements in the Web-based application that allows phone 

representatives to retrieve clinical information about the 

beneficiary (such as date of last pap smear or colonoscopy). The

second phase involves allowing beneficiaries to access clinical 

information about themselves through a Web-based application. 

Food and Drug Administration (FDA)

FDA Structured Product Labeling (SPL)

for prescription products (e.g., 

accessible drug information) 

The SPL provides information found in the approved FDA drug

label or package insert in a computer-readable format for use in 

electronic prescribing and decision support. 

FDA Bar Coding for Prescription

Products 

Standardized labeling.

National Institutes of Health 

NIH National Library of Medicine - 

Grants for Research, Training, and 

Access to Informatics Resources 

Research grants and contracts for advanced computer technologies 

to facilitate access, storage, and use of biomedical information, 

and for the value derived from the adoption, diffusion, and

utilization of HIT. 

NIH National Library of Medicine - 

Grants for Research, Training, and 

Access to Informatics Resources 

Support for training of informatics researchers and developers. 

NIH National Library of Medicine - 

Grants for Research, Training, and 

Access to Informatics Resources 

Support for Integrated Advanced Information Networks (IAIMS), 

Internet connections, and access to digital libraries. 

NIH National Library of Medicine - 

Development and Implementation 

of Controlled Clinical Vocabularies

Support for, and development of, selected CHI standard clinical

vocabularies to enable ongoing maintenance and free use within 

the United States. 

6 
Attachment 4. Federal Health Information Technology Programs 

Agency/ 

Organization Title of HIT Initiative Description of Activities

NIH National Library of Medicine - 

Development and Implementation 

of Controlled Clinical Vocabularies

Uniform distribution and mapping of HIPAA code sets, CHI 

standard vocabularies, HL7 code sets, and other important

vocabularies within the UMLS Metathesaurus. 

NIH National Electronic Clinical Trials 

and Research (NECTAR) Network

NIH plans to develop NECTAR, which will link research sites and 

ultimately create a “national network of networks,” in coordination

with the national health information network, by which research

information and findings will be shared and scientific 

collaborations facilitated. NECTAR includes a research workflow 

model, a common lexicon of standard vocabularies to describe 

medical and scientific events, and analytical and dissemination 

tools. 

NIH Cancer Biomedical Informatics 

Grid (caBIG) 

caBIG is a virtual cancer research network of interconnected data, 

individuals, and organizations that will create a common, widely 

distributed infrastructure that facilitates the sharing of data and 

applications and thereby enhances productivity and efficiency of

research. caBIG infrastructure is based on HHS CHI standards. 

caBIG is being pursued as a pilot program that involves NCI’s 

caCORE central resources, over 40 of NCI’s cancer centers, and 

the FDA. The NCI has created a standards-supporting 

infrastructure called caCORE. It is composed of HHS-established 

controlled vocabularies, standard data elements, and domain 

models. 

Indian Health Service 

IHS Integrated Behavioral Health 

System (BH) 

The BH graphical user interface software application that includes 

the ability to track services provided by social work, 

alcohol/substance abuse counselors, psychologists, and

psychiatrists. Application includes suicide tracking system (with

bi-directional notification within HIPAA guidelines) as well as 

embedded guidelines. The requirements determination has been 

completed and the software development process will begin in

FY04. 

IHS Patient Account Management

System (PAMS) 

The PAMS is an enhanced third-party billing system. 

IHS Clinical Indicator Reporting 

System (CIRS)

The CIRS is a robust reporting system that tracks over 40 

indicators in a standard reporting format. The standards reporting 

format is a delimited file that exports locally into Excel and can be

exported for regional aggregation.

IHS Integrated Case Management 

System

An integrated case management application is being developed to

facilitate three views of data: patient, provider, and population

health. These systems will allow for integration of varied disease 

case management applications that currently exist (diabetes, 

asthma, immunizations, etc.). 

IHS National Data Warehouse Initiative This Initiative is developing a data warehouse for use by

epidemiologists, as well as clinical quality in order to enable

analyses on quality improvement and interface with the clinical 

indicator reporting system. 

IHS Resource and Patient Management

System (RPMS) 

RPMS is the hospital information system utilized by 49 hospitals, 

221 health centers, 120 health stations, and 170 Alaska village

clinics. 

7 
Attachment 4. Federal Health Information Technology Programs 

Agency/ 

Organization Title of HIT Initiative Description of Activities

IHS IHS - EHR Initiative IHS-EHR provides order entry, results reporting, encounter 

documentation, and other clinical functionality to IHS, tribal, and

urban Indian health care providers. IHS-EHR is a component of

the Resource and Patient Management System (RPMS), IHS's 

enterprise health information system. 

Health Services and Resource Administration 

HRSA Shared Integrated Management 

Information Systems (SIMIS)/

Information and Communication 

Technology (ICT) 

The SIMIS/ICT provides hardware, software, and support services 

for integration of practice management systems among federally

supported health centers (SIMIS), and integration of electronic 

health records with practice management systems at consolidated 

health centers (ICT). 

HRSA Integrated Services Development 

Initiative (ISDI) 

The program supports integration efforts in five areas one of which

is information management. 

HRSA Healthy Communities Access

Program (HCAP) 

The HCAP is a community-based program to develop or

strengthen health care safety net delivery systems through 

providing an infrastructure that will coordinate health care for the 

uninsured. Development of information systems is fundamental to

supporting coordination of efforts that increase access to care. 

HRSA Sentinel Centers Network (SCN) The SCN is investing in the information systems of participant 

health centers and networks to provide timely, patient-level data to

inform policy decisions and quality improvement activities across 

all health centers. 

HRSA Patient Electronic Care System

(PECS)

The PECS is a program that is developing patient registry

information systems for centers participating in the Health

Disparities Collaboratives. 

HRSA Office for the Advancement of 

Telehealth grants (OAT) 

Grants support for community-based activities in informatics, 

electronic medical records, and telemedicine, including

telepharmacy. 

HRSA CAREWare CAREWare is a patient, encounter-level software application 

distributed to HIV/Aids Bureau (HAB) grantees and providers of

HIV care to help them manage, monitor, and report on all clinical 

and supportive care services. The software was originally built in

Microsoft Access, but is now being developed in dotNET to

enable Internet and wide-area connectivity of care providers and 

grantees. CAREWare is also being developed for use 

internationally (in Africa especially) under the President’s 

Emergency Plan for AIDS Relief. 

Centers for Disease Control and Prevention 

CDC Public Health Information Network 

(PHIN) 

The CDC is working to advance public health activities through

standards-based information systems. These systems need to work 

with each other and with clinical care systems to support public 

health needs. Through PHIN, the CDC and its public and private 

partners have been advancing software components and data and 

technical specifications that are compatible with federal standards 

activities such as CHI, NCVHS, and eGov. 

CDC PHIN: National Electronic Disease 

Surveillance System (NEDSS) 

NEDSS is an initiative that promotes the use of data and

information system standards to advance the development of

efficient, integrated, and interoperable surveillance systems at 

federal, state, and local levels. 

CDC PHIN: National HealthCare Safety 

Network System

PHIN is an Internet-based system to collect patient data on

measures of health care quality. 

8 
Attachment 4. Federal Health Information Technology Programs 

Agency/ 

Organization Title of HIT Initiative Description of Activities

CDC Public Health Monitoring Most pubic health surveillance and monitoring systems, either 

directly or indirectly, get some data from clinical care activities. 

These data are used to facilitate public health surveillance through

the timely and efficient transfer and processing of appropriate 

public health, laboratory, and clinical care data. Vital statistics 

systems also at times get data that originate in other places in the

health system. 

CDC Clinically Oriented National Center 

for Health Care Statistics (NCHS) 

Monitoring

National Health Care surveys provide a picture of how health care 

is delivered in the U.S. by collecting data from hospitals, 

emergency and outpatient departments, ambulatory surgery

centers, nursing homes, office-based physicians, home health

agencies, hospices, and others on a periodic basis. These surveys 

address measurement of diagnosis and treatment, characteristics of 

health care providers, trends in use of services, characteristics of 

patients, patterns of disease, use of drugs and other treatments, and 

emergence of alternative care sites. 

CDC Public Health Preparedness

Systems 

Preparedness activities such as early event detection,

quantification of outbreak or event magnitude, localization of an

event, investigation of event etiology, the management of possible 

cases, the laboratory confirmation of true cases, the tracing of 

communicable disease contacts, the administration of vaccines, 

prophylaxis, and isolation all potentially interact with clinical-care 

data and systems. The PHIN standards have been requirements of

the CDC and HRSA preparedness supplements to help see that the 

over 2 billion in preparedness funds that have gone to state and 

local health departments and hospitals can meet these information 

exchange goals. 

CDC EPI-X EPI-X is the CDC’s Web-based communications solution for

public health professionals. Through EPI-X, CDC officials, state 

and local health departments, poison control centers, and other

public health professionals can access and share preliminary health 

surveillance information quickly and securely. Users can also be

actively notified of breaking health events as they occur. Key 

features of EPI-X include scientific and editorial support, 

controlled user access, digital credentials and authentication, rapid 

outbreak reporting, peer-to-peer consultation, and CDC-assisted 

coordination of investigations. 

Department of Defense / Veterans Affairs Initiatives 

DoD/VA Joint Plan for the Electronic Health 

Record (JPEHR) 

The JPEHR will provide interoperability between the two health

information systems of VA and DoD. The plan provides for the 

exchange of health data by the departments and development of a 

health information infrastructure and architecture supported by

common data, communications, security, and software standards 

and high-performance health information systems. The plan will 

support Healthy People (federal), Federal Health Information

Exchange (FHIE), Clinical Data Repository/Health Data 

Repository (CHDR), Consolidated Mail Outpatient Pharmacy 

(CMOP), Lab Data Sharing and Interoperability (LDSI), and the 

Centralized Credentials Quality Assurance System

(CCQAS)/VetPro, Scheduling, and E-portal Systems. (Joint DoD 

and VA funding.)

9 
Attachment 4. Federal Health Information Technology Programs 

Agency/ 

Organization Title of HIT Initiative Description of Activities

DoD/VA Telehealth Development and adoption of telehealth capabilities within the 

DoD Military Health System (MHS) and the VA continues to

advance. The steady increase in cooperation between the two

agencies allows for further leveraging of assets, knowledge, and 

development of integrated or interoperable programs. There are six 

joint telehealth initiatives in progress: VA/DoD Imaging 

Subgroup, Teleradiology, Telepsychiatry, Hawaii Integrated 

Federal Health Care Partnership, Alaska Federal Health Care 

Access Network, Case Management (Diabetes), and e-Learning. 

Department of Defense Initiatives 

DoD Clinical Information Technology

Program Office (CITPO) 

CITPO is an acquisition office for centrally managed MHS clinical 

IT systems that support the delivery of health services throughout 

the MHS. The following are CITPO projects: Composite Health

Care System II (CHCSII), Composite Health Care System Legacy, 

Clinical Information System (CIS), Preventive Health Care

Application (PHCA), Defense Blood Standard System (DBSS),

Defense Occupational and Environmental Health Readiness 

System (DOEHRS), Encoder Grouper (EG), Special Needs

Program Management Information System (SNPMIS), TRICARE 

Online (TOL), Nutrition Management Information System

(NMIS), and Veterinary Services Information Management

System (VSIMS). 

DoD Defense Medical Logistics 

Standard Support (DMLSS) 

DMLSS replaces aging military departments' (Army, Navy, and

Air Force MilDeps) specific legacy medical logistics systems with 

one standard DoD medical logistics system. DMLSS also 

manages Joint Medical Asset Repository (JMAR), Customer 

Support on the Web (CSW), Facility Management (FM), Customer 

Area Inventory Management (CAIM), Equipment & Technology

Management (E&TM), Stockroom/Readiness Inventory

Management (SRIM), Assemblage Management (AM), Universal

Data Repository (UDR), Prime Vendor Program (PV), DMLSS - 

Wholesale (DMLSS - W), Customer Demand Management

Information Application (CDMIA), National Mail Order 

Pharmacy (NMOP), Readiness Application (RMA), Medical 

Electronic Customer Assistance (MECA), Distribution and Pricing 

(DAPA) Management System (MS), and Electronic Catalog 

(ECAT). 

10 
Attachment 4. Federal Health Information Technology Programs 

Agency/ 

Organization Title of HIT Initiative Description of Activities

DoD Executive Information/Decision 

Support (EI/DS) 

The EI/DS program provides timely, accurate, and appropriate 

decision information supporting the TRICARE Management

Activity (TMA) and DoD MHS mission. The EI/DS program

currently consists of a data warehouse and several operational data 

marts supporting nearly 3,000 system users, providing a robust

database and suite of decision support tools to empower the 

effective management of MHS health care operations. The EI/DS 

systems support decision making by senior MHS personnel and

post-decision monitoring of the effects of decisions. EI/DS

products include: MHS Management Analysis and Reporting Tool

(MHS MART), Managed Care Forecasting and Analysis System

(MCFAS), Population Health Operational Tracking and 

Optimization (PHOTO), Medical Surveillance, TMA Reporting 

Tools (TMART), CHAMPUS/TRICARE Medical Information 

System (CMIS), CHAMPUS/TRICARE Utilization Reporting 

and Evaluation Systems (CURES), Care Detail Information 

System (CDIS), and Patient Encounter Processing and Reporting

(PEPR). 

DoD Resources Information Technology

Program Office (RITPO) 

The RITPO initiative is a project that consists of a family of 

capability-specific applications/systems that support the MHS 

"Manage the Business" and "Access to Care" and information 

technology requirements. The RITPO project scope includes 

providing information technology support for MHS personnel, 

scheduling, workload forecasting, and patient safety initiatives. 

The following are RITPO projects: Defense Medical Human 

Resources System - internet (DMHRSi), Central Credentials 

Quality Assurance System (CCQAS), Enterprise Wide Scheduling

and Registration (EWS-R), Enterprise Wide Workload Forecasting 

(EWF), Patient Safety Reporting (PSR), and Patient Accounting

System (PAS).

DoD Expense Assignment System IV 

(EAS IV) 

EAS IV is a standard DoD cost accounting/assignment information 

technology system that consists of a cost-assignment application

and a data repository. The system receives information 

electronically from a variety of DoD financial, manpower, and

workload systems, and allocates this expense information to 

Medical Treatment Facility/Dental Treatment Facility (MTF/DTF) 

direct and indirect work centers. 

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Attachment 4. Federal Health Information Technology Programs 

Agency/ 

Organization Title of HIT Initiative Description of Activities

DoD Theater Medical Information 

Program (TMIP) 

TMIP provides a seamless, interoperable medical information 

system to support theater health services during combat or 

contingency operations within and across all echelons of care. The 

primary goal is to provide a global capability linking theater 

medical information databases and integration centers that are 

accessible to the warfighter anywhere, any time to support the 

mission. TMIP includes the following programs: Composite 

Health Care System in the Theater of Operations (CHCS NT), 

Composite Health Care System II - Theater (CHCS II-T), 

TRANSCOM Regulating and Command and Control Evacuation 

System (TRAC2ES), Defense Medical Logistics Standard Support

Assemblage Management (DMLSS-AM), Medical Analysis Tool

(MAT), Shipboard Non-Tactical Automated Data Processing

Program Automated Medical System (SAMS), Medical 

Surveillance System (MSS), and Defense Blood Standard System

(DBSS). 

DoD Third Party Outpatient Collection

System (TPOCS) 

TPOCS is the MHS information system used to bill for ambulatory 

services. 

DoD Telehealth The use of electronic information and telecommunications 

technologies to provide or support clinical health care, patient and

professional health-related education, public health and health

administration when distance separates the participants. Current

projects include Business cases, e-Learning, Policy, 

Teleconsultation, Pediatric Consultation, Telecardiology, 

Teledermatology, TeleENT, Tele Mental Health, 

Teleneurosurgery, Teleorthopedics, Telepathology, Teleradiology, 

Telementoring, and Telemonitoring. 

Department of Veterans Affairs Initiatives 

VA Joint [VA/DoD] Patient Electronic 

Health Record (JPEHR) 

The JPEHR plan will provide interoperability between the two 

health information systems of VA and DoD. The plan provides for 

the exchange of health data by the departments and development

of a health information infrastructure and architecture supported 

by common data, communications, security and software 

standards, and high-performance health information systems. (See 

FHIE.) 

VA Allocation Resource Center (ARC) 

(Health Resources Management)*

The ARC provides IT services for systems designed to support the

VHA CFO's ability to develop, implement, and maintain resource 

allocation methodologies; gather and report on financial aspects of 

patient workload and cost; classify patients based on care and

diagnosis rendered; and train and provide information to

management officials throughout VA. 

VA Decision Support System (DSS)* The DSS transforms day-to-day operational data into tactical 

information that can be used by managers to make informed 

operational decisions. 

VA Decision Support System (DSS) 

Modernization*

The DSS will modernize the existing VA DSS information

technology system through analysis, identification, development, 

and implementation of system architecture that interfaces with 

current and future VA-wide system information technology

structures. 

12 
Attachment 4. Federal Health Information Technology Programs 

Agency/ 

Organization Title of HIT Initiative Description of Activities

VA Fee Basis Replacement (FBR)* The FBR will replace a claims-processing system used by VA that 

processes claims made by veterans and providers for non-VA care.

The new system will ensure effective and efficient authorization 

and payment processing for all non-VA care, including state and 

home health care and community nursing home programs. 

VA Health Administration Center

(HAC) IT Operations* 

The HAC provides a variety of critical programs mandated by 

Congress and facilitates delivery of high-quality services to

veterans and their family members. 

VA Patient Financial Services System

(PFSS)* 

The PFSS will create a comprehensive business solution for 

revenue improvement utilizing improved business practices, 

commercial software, and enhanced VA clinical applications. 

VA Health Enrollment Health Enrollment includes functionality to accept and process 

veterans’ applications for enrollment, share veterans’ eligibility 

and enrollment data with all VA health care facilities involved in

veterans' care, manage veterans' enrollment correspondence and 

telephone inquiries, and support national reporting and analysis of

enrollment data. 

VA Federal Health Information

Exchange (FHIE) 

Provides current and historical data feeds electronically from

CHCS I to the FHIE repository node on selected data types for 

active-duty, retired, and separated service members. 

VA Health Data Repository (HDR) Defined as a repository of clinical information normally residing

on one or more independent platforms for use by clinicians and

other personnel in support of patient-centric care. 

VA Pharmacy Reengineering and IT 

Support

Facilitates improved VA pharmacy operations, customer service, 

and patient safety, concurrent with pursuit of full re-engineering of

VA pharmacy applications. 

VA Scheduling Replacement Will develop a next-generation appointment application based on 

business process re-engineering and the Institute for Health Care 

Improvement guidelines for open and advanced access to care 

models. 

VA VistA Imaging Will provide complete online patient data to health care providers, 

increase clinician productivity, facilitate medical decision making, 

and improve quality of care. 

VA VistA Laboratory IS System

Reengineering 

Will enhance the VA Laboratory Service's information technology

system and associated business processes to address current

deficiencies and meet future needs. 

VA VistA Legacy (includes staff) The operating system software platform and technical 

infrastructure (associated with clinical operations) on which VA 

health care facilities operate their software applications. 

VA Health Infrastructure The health infrastructure is primarily a hardware-refresh project 

designed to put VA general office automation support servers, 

workstations, and peripherals on a 4-year replacement schedule. 

It will consolidate the services of several smaller computer 

facilities into an existing larger computer facility on newer 

hardware, providing greater reliability while reducing overall 

computer space and IT staff. It will establish a working

contingency plan for the consolidated site. 

* Administrative, logistic, and financial systems, which use health data but do not 

contribute to direct patient care. 

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