Electronic Health Records: HHS Needs to Improve Planning and Evaluation of Its Efforts to Increase Information Exchange in Post-Acute Care Settings
Published: 2017-01-27T00:00:00

Fast Facts:
Many patients who leave hospitals receive continuing care from places like rehab facilities (called post-acute care settings). When patients leave the hospitals and move to post-acute care settings, electronic health records can help providers know what the patient needs and better coordinate care.
However, we found that issues like increased costs and a lack of access to technology deter the use of electronic health records in these settings.
We recommended that the Department of Health and Human Services comprehensively plan its efforts to increase the electronic exchange of health information in these settings, and evaluate these efforts.

Highlights:
section_title: Why GAO Did This Study
paragraphs: Many patients who leave hospitals receive care in post-acute settings such as skilled nursing facilities and long-term care hospitals. Exchange of accurate and timely health information is particularly important in these transitions, and technology like EHRs could help to improve quality and reduce costs.
GAO was asked to review issues related to the use of EHRs in post-acute care settings. With regard to post-acute settings, GAO (1) described factors that affect EHR use and electronic exchange of health information and (2) examined HHS efforts to promote EHR use and electronic information exchange. GAO reviewed HHS planning and related documents and best practices for planning identified in prior GAO work. GAO also interviewed HHS officials, and through those interviews and background research identified and interviewed a non-generalizable selection of individuals representing 20 relevant stakeholder groups, including experts, vendors, and professional associations.
section_title: What GAO Found
paragraphs: Stakeholders that GAO interviewed, including experts on electronic health records (EHR) in post-acute care settings, described five key factors that affect the use of EHRs and the electronic exchange of health information in these settings.
Cost: Stakeholders stated that facilities often have limited financial resources to cover the initial cost of an EHR and noted that additional costs may be incurred for exchanging information and for EHR maintenance.
Implementation of standards: Stakeholders expressed concerns with the variability in implementation of health data standards and the difficulty of finding health information relevant to post-acute care providers when this information is exchanged.
Workflow disruptions: Stakeholders stated that implementation of EHRs requires post-acute facilities to change their daily work activities or processes, which can be disruptive.
Technological challenges: Stakeholders stated that they face technological challenges, such as having EHRs that are not capable of electronically exchanging health information.
Staffing: Stakeholders noted that a lack of staff with expertise to manage EHRs and high staff turnover result in a constant need to train staff to use the technology.
The Department of Health and Human Services (HHS) has not measured the effectiveness of each of its efforts to promote the use of EHRs, and it lacks a comprehensive plan to meet its goal of increasing the proportion of post-acute care providers electronically exchanging health information. HHS identified four key efforts related to post-acute care settings; however, the lack of measurement of the effectiveness of these efforts is contrary to leading principles of sound planning. The Office of the National Coordinator for Health Information Technology (ONC) is planning to survey providers in post-acute settings to gather baseline data on the rates of EHR adoption and activities that demonstrate ways to electronically exchange health information. However, these surveys are not intended to assess the effectiveness of HHS's efforts to promote EHR use. In addition, most of the key efforts lack specific plans for evaluating their progress. Therefore, HHS cannot determine if its efforts are contributing to its goal, or if they should be adjusted. In addition, although HHS's goal depends in part on actions by post-acute care providers and EHR vendors, HHS lacks a comprehensive plan with specific action steps to achieve this goal. HHS's planning also does not address how to overcome key external factors that may adversely affect its key efforts. Without a comprehensive plan to address these issues, HHS risks not achieving its goal of increasing EHR use and the electronic exchange of health information in post-acute care settings.
section_title: What GAO Recommends
paragraphs: GAO recommends that HHS (1) evaluate the effectiveness of its key efforts to increase the use of EHRs and electronic information exchange, and (2) comprehensively plan for how to achieve the department's goal regarding the use of EHRs and electronic information exchange in post-acute care settings. HHS concurred with GAO's recommendations.

section_title: Letter
paragraphs: Many patients discharged from acute-care hospitals have a continuing  need for health care services that they can receive in post-acute care  settings, such as long-term care hospitals, inpatient rehabilitation  facilities, skilled nursing facilities, and home health agencies. Providers of  post-acute care can facilitate patients’ continued recovery, helping to  restore medical and functional capacity and prevent health deterioration.  When patients transition from acute care to post-acute care settings, it is  important that the providers share patient health information, such as  health records and test results. This can help coordinate care, avoid  duplication of tests and procedures, and prevent medication and other  errors. However, researchers have estimated that across the health care  system, the costs associated with failed care coordination were between  $25 billion and $45 billion in 2011, and studies have shown that  transitions between acute care settings and post-acute care settings  account for as much as 60 percent of medication errors. The use of health information technology (IT), such as electronic health records  (EHRs), to exchange information during transitions between acute and  post-acute settings can facilitate prompt care coordination and thus has  the potential to help improve health care quality and reduce costs.
Despite the potential benefits of EHRs, available evidence suggests the  use of EHRs is limited in post-acute settings. The Department of Health  and Human Services’ (HHS) Office of the National Coordinator for Health  Information Technology (ONC) reported in its 2013 Issue Brief that there  are no national data on EHR adoption and the electronic exchange of  health information across the different types of post-acute care settings.  At that time, ONC noted that a survey of some post-acute settings— specifically long-term acute care hospitals and rehabilitation  hospitals— conducted in 2009 showed adoption rates for EHRs of six percent and  four percent, respectively. Furthermore, a 2014 survey of post-acute  care providers in New York found that only one-quarter reported receiving  an electronic document when a patient transitioned to their care. In  contrast, ONC has reported that most acute care hospitals possessed  EHRs in 2015.
Neither the Medicare nor Medicaid programs incentivize the use of EHRs  in post-acute care settings. While certain hospitals and health care  professionals are eligible to receive incentive payments through the  Medicare and Medicaid EHR Incentive Program, based on their use of  EHR technology, these “meaningful use” payments do not apply to post- acute care settings.
HHS has set a goal to increase the use of EHRs and the electronic  exchange of information in post-acute care settings, and you asked us for  information on these efforts. In this report, we  (1) describe factors that may affect the use of EHRs and the electronic  exchange of health information in post-care settings, and  (2) examine HHS’s efforts to promote the use of EHRs and electronic  information exchange in post-acute care settings.
To describe factors that may affect the use of EHRs and electronic  exchange of health information in post-acute care settings, we  interviewed 20 stakeholders that represent relevant groups in this area.  We identified a potential pool of stakeholders to interview based on our  background research, and we also asked for suggestions during  interviews with officials at ONC and the Centers for Medicare & Medicaid  Services (CMS), which is responsible for Medicare and Medicaid activities  that relate to post-acute care and EHRs. From that pool, we selected  specific stakeholders that met the following criteria:
Four experts with relevant experience and professional qualifications.
Each expert is also an author of relevant literature or has presented at  relevant conferences or workshops, and is also a member of a  relevant national committee related to health information technology.
Officials from six companies that are vendors of EHRs. These  companies were recommended by other stakeholders, included in a  comprehensive list of post-acute EHR vendors, and have a large  volume of EHRs in the post-acute care market. One of the vendors  also has the largest share of the market for acute-care EHRs.
Officials from six organizations that represent providers and  professionals in post-acute care settings. These organizations have  produced documents related to the use of EHRs in post-acute care  settings and provided comments to HHS related to the use of EHRs in  post-acute care settings.
Officials from four organizations that are recipients of the ONC  Advance Interoperable  Health Information Technology Services to  Support Health Information Exchange Program awards, which fund  programs intended to facilitate EHR use and exchange. We selected  the recipients to include those who focus on post-acute care  providers, represent different types of awardees (including state  governments and non-profit organizations), and represent different  geographic regions.
Using information from those interviews, we categorized the responses to  describe the factors that may affect EHR use. The information we  developed is not generalizable beyond the individuals we interviewed. We  corroborated the information we obtained in these interviews with  information from our background research and our own prior reports.
To examine HHS’s efforts to promote the use of EHRs and electronic  information exchange in post-acute care settings, we reviewed  documentation related to key efforts that were either ongoing or planned  at the time of our work and were specifically directed at post-acute care  settings. We also reviewed supporting documentation related to those  efforts, such as ONC’s Federal Health IT Strategic Plan 2015-2020 and  ONC’s Shared Nationwide Interoperability  Roadmap. We also interviewed  officials from ONC and CMS about the key efforts we identified. We  compared the information and documentation to relevant criteria from  GAO’s body of work on effectively managing performance under the  Government Performance and Results Act of 1993 (GPRA), or the GPRA  Modernization Act of 2010 (GPRAMA).
We conducted this performance audit from March 2016 to January 2017  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Electronic Health Records and the Electronic Exchange of Health Information
paragraphs: ONC defines an EHR as a digital version of a medical record that can  include a person’s medical and treatment history, such as diagnoses,  medications, treatment plans, and more. According to ONC, EHR  systems also can allow access to evidence-based tools that providers use  to make decisions about a person’s care, and they can automate and  streamline provider workflow. ONC states that one of the key potential  benefits of an EHR is that it can allow health information to be created  and managed in a digital format capable of being shared with other  providers across more than one health care organization. This exchange  may occur between hospitals, primary care physicians, specialty  physicians, pharmacies, laboratories, and post-acute care providers. (See  fig. 1.)
Even when providers adopt an EHR system, they may not be able to use  that system to exchange health information with other providers, and the  EHR systems will not necessarily be interoperable with other health IT  systems, including EHRs and health IT systems belonging to laboratories,  specialists, and post-acute care settings. When EHR systems are  interoperable, information can be exchanged—sent from one provider to  another—and then seamlessly integrated into the receiving provider’s  EHR system, allowing the provider to use that health information to inform  clinical care. We previously reported that EHR systems often use different  formats and terminology while exchanging health information, which limits  interoperability.  We also reported that the electronic exchange of health  information and interoperability  relies, in part, on business arrangements  between health care providers who must agree on the rules for exchange,  without which the ability to exchange information may be hampered. As  a result, even when health information can be exchanged electronically,  there is no guarantee that the information can and will be automatically  integrated into the receiving system, and therefore the EHR systems may  not be interoperable. ONC has studied the extent to which non-federal  acute care hospitals performed tasks that demonstrate the ability to be  interoperable. In particular, for 2015 ONC reported the percentage of  surveyed hospitals electronically sending (85 percent), receiving (65  percent), finding (52 percent), and using or integrating key clinical  information (38 percent). According to ONC, even fewer hospitals—about  25 percent—performed all four of these tasks.
Health care providers can use different mechanisms for the electronic  exchange of health care information. For example, if two providers’ EHR  systems are interoperable with each other, then the providers can  electronically share information directly from one provider’s EHR system  to the other provider’s EHR system. Another mechanism is Direct, which  is a set of specifications that allows users to send secure messages,  including documents, to known and trusted recipients over the internet.  With Direct, one health care provider can electronically transmit  documents with health information to another. However, the provider may  send documents with information in a format that is difficult for the  receiving provider to access and consider in a timely or efficient manner,  which can limit the ability to ensure coordination of care and avoid errors.  Another way of electronically exchanging health information is through  health information exchange (HIE) organizations, which are entities that  bring together health care stakeholders within a defined geographic area  to share health information. An HIE organization can facilitate the  electronic exchange of health information by providing data connections among stakeholders, such as laboratories, public health departments,  hospitals, and physicians. We previously identified some concerns  associated with HIEs, including costs.
One of the ways to standardize the information that acute care facilities  and other providers may exchange electronically is by using the  Consolidated-Clinical Document Architecture (C-CDA). It provides a  common structure for sharing information and was developed to help  providers manage a complex set of documents and reduce duplicative  and conflicting standards issued by different organizations. The C-CDA  contains more than 150 templates for information such as allergies,  medications, plan of care, social history, vital signs, functional status,  family history, and more.
section_title: Federal Role in Health Information Exchange
paragraphs: HHS has implemented a series of actions designed to increase the use of  health IT in general and the use of EHRs and electronic exchange of  health information specifically in post-acute care settings.
subsections: section_title: The IMPACT Act and Quality Assessment Reporting Requirements
paragraphs: CMS requires providers in each of four different types of post-acute  facilities—specifically skilled nursing facilities, inpatient rehabilitation  facilities, home health agencies, and long-term care hospitals—to report  certain data that are used for quality measures, resource use measures,  and other types of measures. The Improving Medicare Post-Acute Care  Transformation (IMPACT) Act of 2014 requires, among other things, the  standardization of those data elements—or specific pieces of data—that  providers must report to CMS. Under the IMPACT Act, these data  elements should be standardized in a way that allows for the exchange of  data among post-acute care settings and providers. The first of these  data elements required to be standardized for submission include data on  patients’ functional status, skin integrity (such as pressure ulcers), and  incidence of major falls.
section_title: Federal Health Information Technology Strategic Planning
paragraphs: ONC released the most recent strategic plan for health IT in September  2015, outlining four primary goals, each with its own objectives, for using  health IT to improve the health and well-being of individuals and  communities. One of those goals is to enhance and modernize the  nation’s health IT infrastructure. ONC’s Shared Nationwide  Interoperability  Roadmap (Roadmap), established in 2015, aligns with this  goal in the strategic plan. The Roadmap is a planning document that  proposes specific actions to achieve an interoperable health IT system  nationwide that collectively improves health. The Roadmap includes plans  for the infrastructure needed to support the sharing and use of electronic  health information. The Roadmap includes a specific goal to increase the  proportion of post-acute care providers electronically exchanging health  information. This Roadmap goal relates to the HHS strategic plan goal  of enhancing health IT infrastructure. The strategic plan also notes that  post-acute care settings require access to patient information to ensure  continuity of care and prevent adverse events, such as medication  allergies or errors.
section_title: Certification of EHRs
paragraphs: ONC authorizes certification bodies to (on its behalf) certify whether  health IT, including EHR systems, meet certain functional and technical  requirements and conform to standards and implementation  specifications. Certified EHR technology helps assure purchasers and  other users that an EHR meets the technological and functional  requirements adopted by HHS. Providers that participate in the Medicare  and Medicaid EHR Incentive Programs (which do not include post-acute  care providers) must demonstrate that they are meaningful users of  certified EHR technology. CMS officials noted that EHR selection is provider specific and that CMS has no authority to demand which EHR  system is used by post-acute care providers.
section_title: Five Key Factors Affect EHR Use and Electronic Health Information Exchange in Post-Acute Care Settings
paragraphs: We identified five key factors that affect the use of EHRs and the  electronic exchange of health information in post-acute care settings,  based on our stakeholder interviews: (1) the cost of EHRs, (2)  implementation of standards for EHRs and electronic health information  exchange, (3) the impact of EHRs on workflow, (4) technological  challenges such as lack of EHR capabilities, and (5) the need to train staff  to use EHRs.
Cost: All 20 stakeholders we interviewed described the cost of EHRs and  related technology as a key factor discouraging post-acute care providers  from obtaining EHRs and exchanging health information electronically.  According to a survey of care providers in New York, the costs associated  with the adoption of EHRs in long-term and post-acute care settings  varied significantly. Two-thirds of the surveyed providers reported that  they spent more than $100,000 on EHRs, and nearly 20 percent reported  spending more than $500,000. In addition to the high cost of the initial  purchase of EHR software, stakeholders indicated that post-acute care  providers must also often purchase additional software modules so that  their EHRs can be used to send health information electronically, which is  considered a more advanced function. Furthermore, stakeholders told us  that the additional fees for maintaining an EHR can add more costs in  addition to fees associated with adding the capability to exchange health  information electronically. For example, one stakeholder noted the costs  of connecting EHRs to allow them to be interoperable with other facilities’  EHRs and ongoing maintenance fees that some vendors charge can be  more challenging to pay for than the initial purchase of the EHR.
We previously reported on similar experiences among acute care  providers, who expressed challenges with the upfront costs associated  with purchasing and implementing EHRs, as well as with fees for  participating in state and local HIEs and per-transaction fees for  exchanging health information. According to stakeholders, these costs  are particularly challenging in cases when post-acute care providers have  small profit margins and may therefore not have the financial resources to purchase EHR technology. For example, one stakeholder stated that  post-acute care providers struggling financially will only invest in EHR  systems if they have an incentive to do so, such as the promise of  receiving more patient referrals.
Stakeholders also noted that post-acute care settings did not receive  federal incentives for meaningful use of EHRs aimed at acute-care  hospitals and other providers. Without financial incentives, or a mandate  to adopt EHR technology, there is no business case for post-acute care  providers to adopt EHR technology, several stakeholders told us.  According to stakeholders, post-acute facilities generally do not see an  immediate financial benefit from adopting or using EHRs, because  purchasing and implementing an EHR is expensive and challenging, and  post-acute facilities are not eligible for financial incentives. As a result,  providers may not perceive that the value of an EHR is worth the cost,  and they are less likely to use EHRs. In addition, stakeholders stated that  purchasing an EHR does not result in more revenue for the provider.  CMS officials noted that post-acute care facilities are not eligible to  receive “meaningful use” incentive payments through the Medicare or  Medicaid programs, consistent with the Health Information Technology for  Economic and Clinical Health Act.
Implementation of Standards: There are a number of health data  standards—technical specifications for standardized terminology that  define how information should be packaged and communicated from one  entity to another—to help facilitate the electronic exchange of health  information. However, 19 of the 20 stakeholders we interviewed  described concerns with the implementation of these standards that affect  their use of EHRs and the electronic exchange of health information.  Concerns included variability in the implementation of standards and the  difficulty of finding relevant information when it is exchanged.
Stakeholders stated that variability  in the implementation of standards  allows each post-acute care provider to make individual  adjustments to its  EHR, which can make it difficult to electronically exchange health  information from one provider to another. These statements were similar  to findings from our previous work, in which we found that health IT  standards are not implemented consistently. For example,
One stakeholder said different providers may not store similar data in  the same location within their EHRs, which can cause challenges  when communicating with providers in other health care settings.
Another stakeholder stated there is no universal guidance on how to  apply existing standards; therefore, providers can apply the standards  differently. Other stakeholders added that vendors may implement  standards differently, which creates inconsistencies when exchanging  health information electronically.
Customizing an EHR results in variability of terminology and formatting in  EHR products and may cause difficultly exchanging health information  between two EHR systems. In our previous work, we reported that  information that is electronically exchanged from one provider to another  must adhere to the same standards and these standards must be  implemented uniformly, in order for the information to be interpreted and  used in EHRs, thereby enabling interoperability.
However, even if the implementation of standards were more consistent,  concerns about the length and usability of a major standard, the C-CDA,  would remain. Several stakeholders mentioned limitations with the C- CDA, which is a set of templates that can capture information from one or  more health care encounters and can be exchanged when patients  transfer from one provider to another. Stakeholders reported the C-CDA  is not reader-friendly, includes information that is irrelevant to post-acute  care providers, and is too long to easily find information that is relevant for  post-acute care providers. For example, stakeholders told us that post- acute care providers only need a limited set of information when a patient  transfers from an acute care facility, but stakeholders report that they  typically have to search through as many as 50 to 100 pages of a C-CDA  for the relevant information.
Another concern stakeholders mentioned about the implementation of  standards relates to limitations of certified EHRs for post-acute care  settings. ONC offers certification for EHRs to ensure they meet certain  standards; however, stakeholders told us that there are few vendors that  offer certified EHRs for post-acute care settings. Post-acute care  developers and vendors wishing to certify a health information  technology, including EHRs, must have their product tested and certified  by an approved body to demonstrate that it meets criteria related to  comprehensiveness, functionality, interoperability,  and security. These  criteria were developed by a workgroup of industry representatives and  are designed to support primary clinical needs for post-acute care  providers. The criteria include standards to help facilitate data exchange.  While ONC offers certification of EHR software for post-acute care  settings to ensure that the software meets certain standards and  implementation specifications, this certification is voluntary. One  stakeholder stated that vendors are unlikely to undertake voluntary  certification for their EHR products because it requires an investment of  time and money. According to stakeholders, unless using certified EHR  technology is required, post-acute care providers are not likely to acquire  the certified technology. Furthermore, one stakeholder told us that even if  providers use certified EHRs for post-acute care, those certified EHRs do  not necessarily standardize how providers enter data into an EHR. ONC  officials told us the 2015 health IT certification criteria—the most recent  version—adopted more specific and detailed standards intended to  improve health information exchange. Officials noted, however, that  providers have only recently begun to use technology certified based on  these standards.
Stakeholders also reported that existing standards do not address  challenges related to matching patients with the correct health information  when electronically exchanging information. According to stakeholders we  interviewed, the lack of a standard method to identify patients and match  them to records, such as a national patient identifier for each unique  patient, contributes to these challenges. Many EHR systems use  demographic information, such as a patient’s name, date of birth, and  home address, to match patients with their correct health information. We  have previously reported that challenges matching patients to their health  records can occur because demographic variables do not always yield  accurate results; for example, there could be more than one patient with  the same information. In addition, one stakeholder indicated that if post- acute patients move from their primary residences to long-term care  facilities, their home address may no longer match facilities’ health  records.
Workflow disruptions: Sixteen of the 20 stakeholders mentioned that  providers faced challenges with their workflow—everyday work  processes— when implementing an EHR. For example, stakeholders we  interviewed stated that providers may be reluctant to implement an EHR  because it would require them to make changes to their workflow, which  can be disruptive. For example, one stakeholder stated that they are  more efficient recording information on paper than they would be doing so  electronically.
Stakeholders noted that there were important differences between the  workflow of post-acute care settings and acute care settings that affect  the use of EHRs. As an example, one stakeholder stated that  implementing an EHR is more complicated in a post-acute care setting  because multiple services—such as pharmacy and radiology—are not  located in a single location, which increases the challenge to  interoperability.  In contrast, an acute care setting—such as a hospital— often has all providers in a single location. Other stakeholders pointed out  that patients stay longer in post-acute care settings than they do in an  acute care setting, and that this longer length of stay affects how  information is recorded in EHRs.
Some stakeholders also reported delays of as much as 72 hours when  attempting to electronically exchange health information. Other  stakeholders noted that delays can be caused by inefficient internal  facility workflow processes for electronic exchange, such as needing to  wait for physicians to electronically approve documents. One stakeholder  further stated that printing and faxing a patient’s health information can be  faster than electronic exchange, and therefore providers often use this  method in emergency situations.
Technological Challenges: Sixteen of the 20 stakeholders stated that  technological challenges prevent some facilities from using EHRs or  electronically exchanging health information. For example, one  stakeholder told us that limited internet access in some areas of the  country prevents home health providers from using EHRs, because these  providers cannot rely on being able to access an EHR in patients’ homes.  Furthermore, stakeholders indicated that some post-acute care facilities  may have EHRs that are used primarily for administrative and billing  purposes rather than for clinical care. According to stakeholders, these  EHRs may not be capable of sending and receiving health-related  information electronically and may not have other advanced  functionalities, such as support for clinical decision-making. Finally, post- acute care facilities with an EHR capable of receiving electronic health  information can encounter instances when information is not  automatically integrated into the receiver’s EHR, which can require the  recipient to manually enter data into the EHR.
Staffing: Thirteen of the 20 stakeholders we interviewed identified  staffing challenges at post-acute facilities as a factor affecting their ability  to use EHRs and electronically exchange health information. For  example, stakeholders stated that high staff turnover—which can be from  50 to 100 percent every year—results in a constant need to train new  staff to use the EHR systems. As an example, one stakeholder told us  that EHR vendors may provide a specified number of training hours to  facilities who purchase their EHRs, but this amount of training can be  insufficient due to high turnover.
In addition to high turnover, stakeholders noted that post-acute care  settings may lack information technology (IT) staff to manage the EHR  software and train staff to use the technology. Stakeholders indicated that  many facilities do not have the resources to hire experienced IT  professionals, and therefore the facilities may have few or no qualified  staff to manage EHR software.
section_title: HHS Has Not Measured the Effectiveness of Each of Its Efforts to Promote the Use of EHRs and Lacks a Comprehensive Plan to Meet Its Goal for Post-Acute Care
subsections: section_title: HHS Has Four Key Efforts Designed to Promote the Use of EHRs and the Electronic Exchange of Health Information
paragraphs: ONC and CMS officials identified four key efforts that promote the use of  EHRs in post-acute care settings, including the electronic exchange of  health information. Two of these efforts provide funding to support EHR  use and exchange, and two of the efforts focus on standardizing health  information used in EHRs. As of October 2016, these efforts were  ongoing.
ONC Financial Awards.  ONC has funded cooperative agreements with  state governments and other entities that in turn fund programs that  promote EHR use and health information exchange among post-acute  providers and others not eligible for meaningful use incentives. ONC  provides this funding through its Advance Interoperable  Health  Information Technology Services to Support Health Information Exchange  Program, and funding recipients offer training, education, and technical  assistance to providers, such as assistance with incorporating health  information exchange into their existing workflows. ONC funded 12  awards totaling over $29 million, each covering 2 years of activities from  2015 through 2017. For example, a health information organization in  Nebraska received funding to help nursing homes, home health agencies,  and assisted living facilities adopt Direct messaging, which provides basic  exchange capabilities. Another awardee helps post-acute providers and  others, such as acute care hospitals, electronically exchange health  information by, for example, submitting health information documents to a  state HIE. In addition to their individual activities, awardees are expected  to communicate with each other and with ONC to identify best practices,  such as techniques for explaining to providers the potential benefits of  EHRs and electronic information exchange.
Medicaid Matching Funds. States may also be eligible to receive federal  funding through the Medicaid program to help providers who are not  eligible for meaningful use incentives for HIEs and other related  technology. In February 2016, CMS issued a letter to state Medicaid  directors indicating that federal matching funds (with a 90 percent federal  and 10 percent state match) could be used for these activities. In other  words, states may claim a 90 percent match for Medicaid expenditures  related to electronically connecting eligible providers to other Medicaid  providers, including post-acute care facilities. For example, in order to  increase electronic health information exchange between post-acute care  providers and acute care providers, CMS indicated that states may use  the matching funds to connect post-acute care providers to state HIE  organizations. ONC officials told us that as of October 2016, five states  have received these matching funds, which are not exclusively for post- acute care providers. CMS’s February 2016 letter also indicated that  states may use funds to build web-based provider directories, which  facilitate information exchange by allowing providers to identify relevant  electronic information and the providers who have the capability to send  or receive it. Cloud-based provider directories allow providers without  EHRs to import and export relevant information.
ONC Certification of EHRs for Post-Acute Care. The 2015 Edition of  ONC’s Health IT Certification Criteria supports the certification of health  IT, including EHRs, designed for post-acute settings, though as we have  reported, there is no regulatory requirement or incentive for post-acute  care settings to use certified EHRs. ONC officials told us that the  certification program could provide assurance to post-acute providers that  EHRs offer capabilities providers need, such as the ability to send and  receive key health information, and thereby encourage post-acute care  providers to electronically exchange health information with other  providers. ONC has added and updated the certification criteria to focus on transitions of care from one setting to another, such as from an acute- care hospital to a post-acute setting. For example, the new criteria are  used to assess whether an EHR has the capability to create and receive  C-CDA documents, which are intended to allow electronic transmission of  key health information. Since the ability to certify EHRs to the 2015  criteria began in 2016, ONC has not certified any EHRs that are marketed  for post-acute care settings. However, ONC officials told us that an  industry study of post-acute care vendors indicated that 22 out of 26  vendors have plans to pursue certification for their products.
CMS Data Mapping and Data Element Library. As part of implementing  the IMPACT  Act, CMS has begun to standardize certain data elements,  or pieces of data, which could be used by EHR vendors and providers to  facilitate electronic health information exchange. CMS’s efforts are  focused on the data elements for quality measures calculated using the  patient assessment instruments that post-acute care providers are  required to submit electronically to CMS. The standardization of such  patient assessment data is intended to serve as a centralized health IT  data element resource for providers and vendors, which would make it  easier for post-acute care providers to electronically exchange such data.  For example, CMS is standardizing the patient assessment data  indicating the extent to which patients experience pressure ulcers.  According to CMS officials, these data may then be used both to calculate  quality measures related to pressure ulcers across different post-acute  settings and to electronically exchange information on pressure ulcers  during transitions of care. According to CMS officials, standardized data  elements would allow comparisons of quality across all post-acute care  settings—a goal in the IMPACT  Act. Further, data mapping—which  identifies links between standardized data elements and health IT  standards—could also improve health information exchange during  transitions of care and inform post-acute care discharge planning. CMS  officials told us that the Data Element Library was still in development as  of December 2016 and that they are on track to meet the 2019 deadline  set by the IMPACT Act.
As CMS works toward standardizing post-acute care assessment data  elements, CMS officials said they are beginning to link the standardized  data elements to more widely used health IT standards that support electronic health information exchange. For example, standardized  patient assessment data elements on clinical concepts may be linked to  Logical Observation Identifier Name Codes, known as LOINC, a broader  health IT standard used for laboratory and clinical observations.  According to officials, the standardized data elements will do a better job  of facilitating electronic health information exchange if they help ensure  that post-acute providers send and receive the same data elements.  Additionally,  CMS is creating a Data Element Library to make the details  of the standardized data elements available to key stakeholders.  According to CMS officials, information from the Data Element Library  could support vendors as they develop EHR products for post-acute care  providers by using the standardized data elements linked to nationally  accepted health IT standards, and thereby increase the capacity to  electronically exchange health information. CMS officials envision that  software vendors could use the information to develop EHR products with  the capacity to inform care planning and sharing of long-term and post- acute care assessment summary documents, which in turn could facilitate  more coordinated care and improve beneficiary outcomes.
CMS officials told us that they plan to make the Data Element Library  available to the public to support standardization efforts and  interoperability  of the post-acute care assessment data elements in the  near future. However, CMS officials told us that this is a long-term project  and CMS does not have a more specific timeframe for this effort. In  addition, there is no requirement that post-acute care providers or  vendors use the standards associated with data elements that are part of  this effort. Further, the standardized assessment data elements used for  IMPACT  Act reporting, or content from the Data Element Library, do not  include all clinical content found in an EHR, since those standardized  data elements focus only on post-acute care assessment data required  for reporting to CMS. For example, many EHRs collect information on  laboratory results. The Data Element Library would not currently contain  this information, since post-acute care assessments do not currently  include data elements for laboratory results.
section_title: HHS Has Not Measured the Effectiveness of Each of Its Key Efforts to Promote the Use of EHRs and the Electronic Exchange of Health Information in Post-Acute Settings
paragraphs: HHS does not have information on the effectiveness of its four key efforts  to promote EHRs and the electronic exchange of health information in  post-acute settings. HHS has plans to evaluate two of its four key efforts,  one of which has several limitations, and it lacks any plan for two of the  key efforts, as described below.
ONC Financial Awards:  HHS has a plan to evaluate ONC’s financial  award program. Currently, ONC tracks each awardee’s progress on  specific activities that the awardees agree to perform using a series of  milestones and metrics. Specifically, awardees must work with clinical  and non-clinical care providers and individuals to establish reporting  mechanisms, set goals, and track progress on required health information  exchange milestones, including tracking the rates at which providers or  others send, receive, find, and use available health information. They  must also determine whether this information improves health or health  care. In addition, awardees must submit quarterly progress reports to  ONC and participate in monthly phone calls to discuss their progress.  According to ONC officials, a more complete program evaluation will be  conducted once the program is finished. However, officials have not  specified what the evaluation will entail, and it is too early to know if this  evaluation will allow ONC to determine how the program may contribute  to HHS’s goal of increasing EHR use and the electronic exchange of  health information among post-acute providers.
ONC Certification of EHRs in Post-Acute Care: HHS has a plan for  evaluating the number of post-acute care settings that have an EHR;  have a certified EHR; can send, receive, find and use electronic health  information; and have information electronically available at the point of  care. However, the plan has limitations. ONC plans to evaluate the extent  to which post-acute care providers use certified EHR products by adding  a question about certification to its ongoing surveys of home health  agencies and skilled nursing facilities (discussed in more detail below). A  separate ongoing survey that includes long-term acute care hospitals and  inpatient rehabilitation facilities currently has a question that focuses on  whether providers are using EHRs that are certified as eligible for  meaningful use incentives. Because post-acute providers are not eligible  for these incentives, however, it is unclear how this question will  adequately assess whether providers are using EHR products that have  received certification under ONC’s voluntary certification program for  post-acute care providers. ONC officials told us that the survey will not  collect data on how the voluntary certification program may or may not  affect post-acute care providers’ decisions to adopt or use EHRs. Rather,  ONC hopes to use the data—along with additional data, such as  programmatic data from ONC’s certification effort —to assess correlations  between the adoption of certified EHRs and the likelihood that post-acute  care providers send, receive, locate, or integrate electronic health  information.
Medicaid Matching Funds and CMS Data Mapping: Finally, HHS does  not have any plans to evaluate its other two key efforts—the use of  Medicaid matching funds or the data mapping and Data Element Library.  Once the Data Element Library is made publically available,  ONC officials  told us they expect to explore opportunities to evaluate its possible effects  on the Roadmap’s goal related to interoperability  and health information  exchange in post-acute care settings. Without specific evaluation plans, it  is not clear how CMS will measure the success of either of these efforts.
In addition to the limited evaluation plans geared specifically for HHS’s  four key efforts, ONC officials told us that ONC is planning to survey  providers in all four post-acute settings to gather baseline information  about the rates of EHR adoption and the extent to which post-acute care  providers are engaging in activities that demonstrate interoperability— specifically, sending, receiving, finding, and integrating electronic health  information. Subsequent surveys could be used to identify progress  towards expanding EHR use and the electronic exchange of health  information. ONC officials told us that the agency plans to obtain survey  data from two sources. First, the agency plans to use an ongoing annual  survey of hospitals, conducted by the American Hospital Association, to  gather baseline data on long-term care hospitals and inpatient  rehabilitation facilities. This mail survey has collected data on these  facilities since 2012. Second, ONC officials told us the agency is  developing a similar phone survey for home health agencies and skilled  nursing facilities. The officials told us that the agency fielded both surveys  at a similar time in October 2016 and plans to analyze baseline data in  2017. ONC officials told us that the agency plans to fund data collection  regarding the long-term care hospital and inpatient rehabilitation survey  until at least 2018. They also said that the agency would like to conduct a  follow-up survey for the other settings in 2018; however, ONC officials are  uncertain as to whether they will have the funding for this effort.
ONC officials expect the surveys to provide useful information on rates of  EHR adoption and activities that demonstrate interoperability, but officials  say that the surveys are not intended to assess the effectiveness of  specific HHS efforts designed to promote EHRs use in a post-acute care  setting. For example, because the survey of home health agencies and  skilled nursing facilities is being done by phone—which officials  determined would be the most cost-effective method—it does not include  detailed questions about factors that affect EHR adoption, use, and the  electronic exchange of health information in post-acute care settings. In  contrast, the ongoing annual survey of long-term care hospitals and  inpatient rehabilitation facilities uses a written format and includes some  questions that may provide greater detail. However, the differing formats  and content of these surveys limit comparisons of results across different  facility types.
The lack of detailed plans to promote the use of EHRs and the electronic  exchange of health information in post-acute care settings is inconsistent  with leading principles on planning we have identified in prior work. These  principles state that detailed evaluation plans are an important way for  agencies to measure progress and to identify which efforts may or may  not be successful in achieving agency goals. Without an evaluation plan  for all of its four key efforts, HHS cannot determine whether or to what  extent its efforts are contributing to the department’s overall goals, or if  these efforts need to be adjusted.
section_title: HHS Lacks a Comprehensive Plan with Specific Action Steps and Consideration of External Factors to Achieve Its Goal for Post-Acute Care
paragraphs: HHS’s ongoing activities to increase EHR use and the electronic  exchange of health information are intended to help achieve the goal of  ONC’s Roadmap to increase the proportion of post-acute care providers  electronically exchanging health information by 2017. However, HHS  does not have a comprehensive plan to achieve this goal. While the  Roadmap serves as a general plan, neither it nor other planning  documents are comprehensive. First, these documents do not clearly  outline how these individual  key efforts will work together to meet the  Roadmap goal. Second, the documents lack certain other elements that  are desirable for a strategic plan so that HHS will be able to achieve its  goal within its specified timeframes. According to leading principles of  sound planning identified in our prior work, these elements include a plan  with specific action steps and the identification and consideration of  external factors. (See fig. 2.) The lack of a comprehensive plan with  specific action steps and the failure to consider external factors, such as  cost and high staff turnover, in the Roadmap may adversely affect the  implementation of HHS’s key efforts and thus the ability of HHS to  achieve the Roadmap’s goal for post-acute providers.
A Plan with Specific Action Steps. HHS officials indicated that while  achieving the goal of the Roadmap depends in part on actions by post- acute care vendors and providers, the Roadmap does not address how to  facilitate or encourage vendor and provider actions. For example, CMS  officials told us they hope that by standardizing post-acute care  assessment data elements and linking these data elements to health IT  standards in its Data Element Library, post-acute care vendors will use  these data elements to create technological solutions for post-acute care  settings. CMS officials told us that the agency intends to notify the public,  including stakeholders and vendors, when the Data Element Library is  complete. Since the library is meant to serve as a resource, there are no  requirements for vendors to use the data elements to improve EHR  systems or for post-acute care providers to use the improved systems.  CMS, therefore, has no plans to ensure that vendors use these data  elements to improve EHR systems, or that post-acute providers use the  improved systems—both of which would be key steps necessary to  achieve the Roadmap’s goal. Furthermore, in its certification program,  HHS has not outlined specific action steps for post-acute care vendors or  providers to take. For its part, ONC has provided guidance on  functionality to vendors serving providers not eligible for the meaningful  use incentives. ONC sees its certification of EHR technology as a chance  to provide assurance to post-acute care providers that certain EHRs have  functionality and standards and can support exchange with other settings,  such as hospitals. ONC officials told us they hope there is an increase in  the use of certified products among post-acute care settings, and the  officials say they will continue outreach to and education for post-acute  providers regarding the program and relevant certification criteria.
Identification and Consideration of External Factors. ONC officials  told us that the Roadmap is a high-level document describing the  department’s vision of an interoperable health care system. The officials  added that this document therefore does not discuss in detail how  external factors, such as costs, high staff turnover, lack of technical  support, and workflow challenges may affect the extent to which post- acute care settings use EHRs and electronically exchange health  information. While HHS has key efforts that may help to achieve the  Roadmap’s goal, these key efforts are unlikely to fully address these  external factors. For example, while ONC financial awards and Medicaid  matching funds may eventually  help to make health information exchange  more affordable for post-acute facilities, these funds are not intended to  address the full range of factors reported by the 20 stakeholders we  interviewed. Furthermore, some of the factors may be outside of HHS’s  control and may require action by external stakeholders. By not planning  for how to address external factors that could significantly affect EHR use  and the electronic exchange of health information for post-acute care  settings, HHS runs the risk that these factors could impede progress  towards its goal.
section_title: Conclusions
paragraphs: HHS has several key efforts to promote EHR use and the electronic  exchange of health information in post-acute care settings. However,  HHS lacks plans for fully evaluating the effectiveness of each of these  efforts.  As a result, it will be difficult for HHS to determine whether any of  its efforts contributed to that increase, and if any of its efforts should be  modified to increase their effectiveness.
Furthermore, HHS’s Roadmap and other planning documents do not  clearly outline how these individual efforts will work together to meet  HHS’s goal for the electronic exchange of health information in post-acute  settings. Describing how efforts will work together is an important part of  comprehensive planning. Given that vendors and providers play an  important role in whether HHS achieves its goals, it is problematic that  HHS has not developed a comprehensive plan with specific action steps  that specifically address how to facilitate or encourage vendor or provider  actions. Additionally,  HHS’s Roadmap does not specify the external  factors that affect post-acute provider’s use of EHRs and the electronic  exchange of health information, such as the many providers who do not  see immediate financial benefits in adopting or using EHRs. Without  comprehensive planning, HHS risks not achieving its goal of increasing  the proportion of post-acute providers that send, receive, find, and use  electronic health information by 2017.
section_title: Recommendations for Executive Actions
paragraphs: To improve efforts to promote EHR use and electronic exchange of health  information in post-acute care settings, we recommend that the Secretary  of Health and Human Services direct CMS and ONC to take the following  two actions:
Evaluate the effectiveness of HHS’s key efforts to determine whether  they are contributing to HHS’s goal for increasing the use of EHRs  and electronic exchange of health information in post-acute care  settings.
Comprehensively plan for how to achieve the department’s goal  related to the use of EHRs and electronic information exchange in  post-acute care settings. This planning may include, for example,  identifying specific actions related to post-acute care settings and  identifying and considering external factors.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS for comment. HHS provided  written comments, which are reprinted in appendix I, and technical  comments, which we incorporated as appropriate. In its written  comments, HHS concurred with our recommendations and described  some of HHS’s efforts to promote EHR use and electronic exchange of  health information in post-acute care settings. Regarding our first  recommendation, HHS stated that a first step in evaluating its efforts is to  establish baseline metrics to assess the current situation. Regarding our  second recommendation, HHS stated that it intends to develop  comprehensive planning to achieve its goal, including working with  stakeholders to advance the use of EHRs in post-acute settings and to  address barriers and external factors.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretary of Health  and Human Services and other interested parties. In addition, the report  will be available at no charge on the GAO website at http://www.gao.gov.  If you or your staff have any questions about this report, please contact  me at 202-512-7114 or yocomc@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in Appendix II.
section_title: Appendix I: Comments from the Department of Health and Human Services
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov.
section_title: Staff Acknowledgments
paragraphs: In addition to the contact name above, Will Simerl (Assistant Director),  Carolyn Feis Korman (Analyst-in-Charge), Courtney Liesener, and Ashley  Nurhussein made key contributions to this report. Also contributing were  Muriel Brown, Krister Friday, Monica Perez-Nelson, and Rebecca Rust  Williamson.