Electronic Health Records: Nonfederal Efforts to Help Achieve Health Information Interoperability
Published: 2015-09-16T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: EHR interoperability is viewed by many health care stakeholders as a necessary step toward improving health care. However, interoperability has remained limited. Although the federal government plays a key role in guiding movement toward interoperability, many of the actions are to be completed by nonfederal stakeholders.
GAO was asked to review the status of efforts by entities other than the federal government to develop infrastructure that could lead to nationwide interoperability of health information. This report describes the (1) characteristics of selected nonfederal initiatives intended to facilitate EHR interoperability, and (2) key challenges related to EHR interoperability and the extent to which selected nonfederal initiatives are addressing these challenges. GAO interviewed representatives from 18 selected nonfederal initiatives that were frequently mentioned by stakeholders GAO interviewed, and reflected a range of approaches. GAO reviewed documents from these initiatives as well as other published research.
section_title: What GAO Found
paragraphs: Representatives from the 18 nonfederal initiatives GAO reviewed described a variety of efforts they are undertaking to achieve or facilitate electronic health record (EHR) interoperability, but most of these initiatives remain works in progress. EHR interoperability is the ability of systems to exchange electronic health information with other systems and process the information without special effort by the user, such as a health care provider. These initiatives' efforts include creating guidance related to health data standards, encouraging the adoption of certain health data standards or policies that facilitate interoperability, and operating networks that connect EHR systems to enable interoperability. The initiatives varied in a number of other ways, including the types of electronic systems the initiatives are working to make interoperable, the cost of their products or services, the geographic area served, patient use of the products or services, and their organizational structures. For example, GAO found that while some initiatives are making their products or services available at no cost, others are charging a fee for their products or services based on the type of entity using the product or service (e.g., individual physician or hospital) or the amount of data exchanged. Similarly, over half of the initiatives were using varying approaches to facilitate patient access to and control over their health information. The majority of the initiatives GAO selected are still in the process of developing, or encouraging others to adopt, their products or services. Most of the initiatives' products or services were not widely available at the time of GAO's review, but initiative representatives anticipated greater availability of their products or services in the next 2 years.
Stakeholders and initiative representatives GAO interviewed described five key challenges to achieving EHR interoperability, which are consistent with challenges described in past GAO work. Specifically, the challenges they described are (1) insufficiencies in health data standards, (2) variation in state privacy rules, (3) accurately matching patients' health records, (4) costs associated with interoperability, and (5) the need for governance and trust among entities, such as agreements to facilitate the sharing of information among all participants in an initiative. Representatives from the 18 initiatives GAO reviewed said they are working to address these key challenges using different approaches. Each key challenge is in the process of being addressed by some initiatives. To move interoperability forward, initiative representatives noted, among other issues, that providers need to see an EHR system as a valuable tool for improving clinical care.
The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: Electronic health record (EHR) interoperability is viewed by many health  care stakeholders as a necessary step toward transforming health care  into a system that can achieve goals of improved quality, efficiency, and  patient safety. EHR interoperability refers to the ability of EHR systems to  exchange electronic health information with other systems and process  the information without special effort on the part of the user, such as a  health care provider. 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.
The Department of Health and Human Services’ (HHS) Office of the  National Coordinator for Health Information Technology (ONC) is charged  with promoting the adoption and use of health information technology by  the Health Information Technology for Economic and Clinical Health  (HITECH) Act, part of the American Recovery and Reinvestment Act.  ONC has stated that EHR interoperability is key to its vision of enabling  every individual and his or her health care providers to access the health  information they need in a useful electronic format when and how they  need it. Although ONC has reported nationwide progress on the extent to  which providers can exchange health information among different data  systems and organizations, it has also reported that interoperability  remains limited due to, among other things, electronic health information  not being sufficiently structured or standardized, a lack of financial  motives, and misinterpretation of existing laws governing the sharing of  health information.
In its January 2015 draft “Interoperability Roadmap,” ONC identifies  critical actions for public and private sector stakeholders to take to enable  nationwide interoperability of electronic health information in the near  term. Although ONC plays a key role in convening stakeholders and  guiding movement toward interoperability, many of these actions are  slated for completion by public and private stakeholders.
You asked that we review the status of efforts by entities other than the  federal government to develop infrastructure needed to support  nationwide interoperability of health care information. In this report, we  1.  examine the characteristics of selected nonfederal initiatives that are  intended to facilitate EHR interoperability, and  2.  describe the key challenges related to EHR interoperability and the  extent to which selected nonfederal initiatives are addressing these  challenges.
To examine the characteristics of selected nonfederal initiatives that are  intended to facilitate EHR interoperability, we first identified nonfederal  organizations that have ongoing initiatives (nonfederal initiatives) that  facilitate interoperability by reviewing recent articles from health  information technology (IT) news outlets and interviewing stakeholders,  such as the College of Healthcare Information Management Executives,  the Healthcare Information Management Systems Society, the American  Medical Association, and Patient Privacy Rights. We defined nonfederal  initiatives as projects or programs outside of the federal government that  are intended to facilitate EHR interoperability related to the provision of  clinical care (as opposed to research). Our goal was not to identify all  interoperability initiatives, but rather to develop a list that included a  variety of initiatives working to facilitate EHR interoperability. We obtained  feedback from ONC to determine the completeness and accuracy of our  list and then judgmentally selected initiatives for our review. From our  initial list of 39 initiatives, we selected 18 for review that were frequently  mentioned by stakeholders we interviewed, and reflected a range of  approaches. We interviewed representatives from these 18 initiatives to  obtain detailed information about each initiative, including information  about each initiative’s governance structure, funding, product  development status, timeline, and extent to which the initiative will enable  interoperability (e.g., among different providers and types of health  information to be made interoperable). (See appendix I for a list of these  initiatives.)
To describe the key challenges related to EHR interoperability and the  extent to which selected nonfederal initiatives are addressing these  challenges, we first identified key challenges by reviewing our 2014 report  and interviewing stakeholders to determine the most frequently cited key  challenges to achieving EHR interoperability. We confirmed identified  challenges during interviews with representatives from the 18 initiatives  we selected to review. We asked initiative representatives about the  extent to which their initiatives are taking steps to address these key  challenges, as well as any other challenges related to EHR  interoperability. When available, we obtained relevant documentation  from initiatives, such as bylaws, governance documents, or technical  plans, to learn more about the extent to which the selected initiatives are  addressing or have plans to address key challenges related to EHR  interoperability. We also asked representatives from the 18 initiatives to  discuss other actions that may be needed to move interoperability  forward.
The initiatives we reviewed were selected judgmentally; therefore, any  information gathered from our interviews cannot be generalized.  Consequently, we are not presenting all approaches to achieving EHR  interoperability, all the challenges related to EHR interoperability, or all  actions needed to move EHR interoperability forward. In addition, we did  not evaluate the initiatives’ current or planned efforts to implement  interoperability activities or the efforts undertaken by the initiatives to  address the challenges.
We conducted this performance audit from April 2015 to September 2015  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
paragraphs: An EHR is a digital version of a patient’s paper medical record or chart.  EHRs ideally make information available instantly and securely to  authorized users. An EHR can contain the medical and treatment history  of a patient, diagnoses, medications, treatment plans, immunization  dates, allergies, radiology images, and laboratory and test results. An  EHR can also give a provider access to evidence-based tools for making  decisions about a patient’s care and can automate certain workflows.  EHR system software is typically purchased by providers (such as  physicians, hospitals, and health systems) from vendors that develop the  systems. 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.
HHS and others view EHR system interoperability as a necessary step  toward transforming health care into a system that can achieve goals of  improved quality, efficiency, and patient safety. For example, use of  interoperable EHR systems could better enable health care providers to  view results from diagnostic procedures conducted by other providers  to avoid duplication; evaluate test results and treatment outcomes over time regardless of  where the care was provided to better understand a patient’s medical  history;  share a basic set of patient information with specialists during  referrals and receive updated information after the patient’s visit with  the specialist to improve care coordination;  view complete medication lists to reduce the chance of duplicate  therapy, drug interactions, medication abuse, and other adverse drug  events; and  identify important information, such as allergies or preexisting  conditions, for unfamiliar patients during emergency treatment to  reduce the risk of adverse events.
Health data standards are technical requirements used to, among other  things, facilitate health information exchange and interoperability of  systems, including EHR systems. Such standards consist of terminology  and technical specifications that, when adopted by multiple entities,  facilitate the exchange and interoperability of health information. Health  data standards include, for example, standardized language for  prescriptions and laboratory testing. Standards define how information is  packaged and communicated from one entity to another, setting the  language, structure, and data types required for integration between the  systems. Standards generally have been developed by nonfederal  standard development organizations and are accompanied by  implementation guides, which can help ensure that standards are  implemented uniformly. Consistent implementation of the standards by  the vendors that build and sell EHR systems and by providers who use  these systems is necessary for interoperability.
The Medicare and Medicaid EHR Incentive Programs are intended to  help increase the adoption and meaningful use of EHRs by providing  incentive payments for providers—that is, certain hospitals and health  care professionals such as physicians—who participate in Medicare and  Medicaid, and later imposing payment adjustments, also referred to as  penalties, on those Medicare providers that do not meet meaningful use  requirements for a program year. Within HHS, ONC and the Centers for  Medicare & Medicaid Services (CMS) develop the programs’  requirements. CMS establishes specific requirements providers must  meet to qualify for incentive payments. Some of these requirements  include the exchange of health information, which is a component of  interoperability. ONC identifies health data standards and technical  specifications for EHR systems and certifies EHR systems used by  providers in the program to help ensure that providers implement a  system that offers a minimum level of technological capability,  functionality, and security. In order for an EHR system to be certified, it  must adhere to requirements related to health information exchange,  among other capabilities.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996  and its implementing regulations, the Privacy Rule, regulate covered  providers’ use and disclosure of personal health information. Providers  may also be subject to additional state privacy rules, which can be more  stringent than HIPAA requirements or standards. For example, states can  set requirements around default practices for health information  exchange. Specifically, states that require patients to “opt-in” to health  information exchange do not allow the sharing of health information  unless patients affirmatively consent to share health information. States  with “opt-out” policies around health information exchange permit, by  default, the automatic sharing of patient health information, and patients  must affirmatively express their preference to not have information shared  if they do not want it exchanged.
section_title: Initiatives Described a Variety of Approaches for Addressing Interoperability and Are Generally Works in Progress Selected Initiatives Vary in a Number of Ways, Including Their Products or Services and Membership
paragraphs: The initiatives we reviewed vary in their efforts to achieve or facilitate  interoperability, including (1) the primary products or services they offer  (e.g., a network or guidance for implementing standards), (2) the types   of electronic systems the initiatives are working to make interoperable,   (3) the cost of the initiatives’ products or services, (4) the geographic  areas served by the initiatives, (5) the extent to which initiatives facilitate  patient access to their health information, (6) the stakeholder groups that  are members of the initiatives, and (7) the sources of funding for the  initiatives.
subsections: section_title: Most of the Selected Interoperability Initiatives Are Relatively New and Still Undergoing Development
paragraphs: The majority of the initiatives we selected are works in progress, meaning  that they are relatively new and therefore still in the process of  developing, or encouraging others to adopt, their products or services. Of  the 18 initiatives we selected, 10 began after January 2013.  Representatives from 6 of the initiatives said that their primary products or  services were available in some areas or available on a limited scale;  however, according to the representatives, none of their products or  services were widely available or widely used at the time of our review.  For example, representatives from the 4 initiatives associated with HIE  organizations said that they are actively facilitating interoperability, but  this interoperability is confined to a single state or region. The 2 other  initiatives have products available, but according to representatives, the  initiatives are in the very early stages of deploying those products and  anticipate that use of their products will increase by 2016.  Representatives from 7 of the initiatives stated that their products or  services are currently being developed and would not be available until  the end of 2015 or sometime in 2016.
section_title: Stakeholders and Initiative Representatives Described Five Key Challenges to EHR Interoperability, Efforts to Address These Challenges, and Other Barriers
paragraphs: Stakeholders and initiative representatives we interviewed described five  key challenges to EHR interoperability, and initiative representatives  described how they are working to address these challenges using  different approaches. Initiative representatives also identified other issues  beyond the scope of their initiatives that they say need to be addressed in  order to move nationwide EHR interoperability forward.
subsections: section_title: Stakeholders and Initiative Representatives Described Five Key Challenges to EHR Interoperability
paragraphs: Stakeholders and representatives from the selected EHR initiatives  described five key challenges to achieving EHR interoperability:   (1) insufficiencies in standards for EHR interoperability, (2) variation   in state privacy rules, (3) accurately matching patients’ health records,   (4) costs associated with interoperability, and (5) need for governance  and trust among entities.
subsections: section_title: Insufficiencies in Standards for EHR Interoperability
paragraphs: While standards for electronically exchanging information among EHR  systems exist, stakeholders and initiative representatives said that these  standards are not sufficient for achieving EHR interoperability. This  challenge stems from the fact that some standards are not specific  enough and, as a result, the systems that implement these standards  may not be interoperable. According to some stakeholders, some  standards allow EHR systems to use different formats and terminology  when exchanging data. However, this resulting variability prevents the  receiving system from processing the information and properly integrating  it into the patient record; in other words, the systems are not  interoperable. 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.
section_title: Variation in State Privacy Rules
paragraphs: Stakeholders and initiative representatives said that exchanging health  information with providers in other states, which is necessary for  nationwide EHR interoperability, can be difficult. This challenge exists  because of variations in privacy rules from state to state, especially  variation in laws pertaining to patient consent for sharing health  information. According to a representative from one initiative, providers in  opt-in states may be hesitant to exchange health information with  providers in opt-out states if the providers lack assurance that the patients  have explicitly consented to the exchange.
This challenge may be more pronounced when exchanging certain types  of sensitive information, such as mental health information or HIV status,  among providers in different states. Some states require additional patient  consent when exchanging such information. A representative from one  initiative explained that current digital methods for exchange do not  provide assurance that sensitive information is protected in accordance  with privacy rules. According to this initiative representative, the sensitive  information that is subject to more stringent privacy rules could be  inadvertently aggregated with other health information and exchanged  without the patient’s consent, thereby violating privacy rules.  Representatives from one initiative noted that they specifically do not  include any mental health information in electronic health information  exchange, even with patient consent, because of concerns about  inadvertently violating privacy rules.
section_title: Accurately Matching Patients’ Health Records
paragraphs: Stakeholders and initiative representatives said that another key  challenge to EHR interoperability is accurately matching patients’ health  records that are stored in different systems. This challenge exists  because many EHR systems use demographic information, such as a  patient’s name and date of birth, to match different health records for a  given patient held by different providers. As we previously reported,  demographic variables do not always yield accurate results because, for  example, there could be more than one patient with the same  information. In addition, providers may not collect and use the same  demographic variables for matching. For example, one initiative  representative explained that a recent effort to achieve interoperability  with another organization stalled because the other organization relies on  a patient’s social security number for patient matching, but the initiative  does not collect social security numbers for its patients. In addition, some  methods to match records for the same patient across providers can fail  because of differences across EHR systems in data formats or because  of missing data from or inaccurate data in some health records.
section_title: Costs Associated with Interoperability
paragraphs: Stakeholders and initiative representatives said that the costs associated  with achieving interoperability can be prohibitive for providers. This  challenge exists in part because of the high cost of EHR customization  and legal fees associated with interoperability. One stakeholder said that  many EHR systems require multiple customized interfaces—which are  specially designed connections to other health IT systems—in order to  facilitate interoperability with other providers and organizations. The costs  associated with these customized interfaces are typically paid by the EHR  buyers (i.e., providers). Representatives from some initiatives added that  the legal fees associated with establishing EHR interoperability can also  be significant. For example, as the next section describes, certain  agreements may need to be established as a precondition to  interoperability.
section_title: Need for Governance and Trust among Entities
paragraphs: Stakeholders and initiative representatives said that it can be challenging  to establish the governance and trust among entities that are needed to  achieve interoperability. These governance practices can include  organizational policies related to privacy, information security, data use,  technical standards, and other issues that affect the exchange of  information across organizational boundaries. One stakeholder noted that  it is important to establish agreements to ensure that entities share  information openly with all other participants in a network. However,  representatives from one initiative noted that there is some risk that the  various agreements developed by different EHR initiatives could result in  conflicting organizational policies. For example, the representative  explained that participants in one initiative cannot participate in another  initiative because the initiatives’ organizational privacy policies do not  align.
section_title: Each Key Interoperability Challenge Is in the Process of Being Addressed by at Least Some Initiatives
paragraphs: Representatives from all 18 of the initiatives we reviewed said they are  working to address these key challenges using different approaches (see  table 1).
Fifteen of the 18 initiatives are working to address insufficient standards  needed to achieve EHR interoperability. Representatives from 7 of the  15 initiatives told us that they are developing instructions for implementing  standards in ways that enhance interoperability. For example, 1 initiative  provides precise definitions of how different standards can be  implemented to meet specific clinical needs, such as locating information  about a patient that is contained in other organizations’ EHR systems.  This initiative also provides an opportunity for vendors to test that they  have successfully incorporated these instructions into their products. Four  of these 7 initiatives are working to develop instructions for implementing  existing standards, and 3 are working to develop instructions for  implementing a new standard that representatives said will improve  systems’ ability to interoperate.
Representatives from 8 of the 15 initiatives told us that they require  organizations to adopt common technical requirements as a condition of  participation in the initiative. For example, representatives from 1 initiative  said that it requires participants to adopt specific implementations of  standards that enable functions like sharing health care information  between entities. Representatives from 5 of the 8 initiatives told us that  they also require participants to test their systems to confirm that the  systems are able to interoperate with the systems of other initiative  participants. For example, 1 initiative provides an online testing tool that  vendors and providers must use to assess and demonstrate  interoperability before joining the initiative. In addition to requiring  agreement on technical requirements, 2 of the 8 initiatives said that they  provide semantic normalization—that is, translation of data between  different formats and terminology—in order to accommodate variation  between organizations exchanging information and enable  interoperability. One initiative representative predicted that there will  always be a need for some semantic normalization as part of  interoperability because it is unlikely that all organizations will adopt the  same standards in exactly the same way.
Representatives from initiatives expressed differing opinions on additional  actions that are needed to fully address the challenge of insufficient  standards, including the role of the federal government in addressing the  issue. Representatives from three initiatives said that there is a need for  federal leadership on standards and their implementation. Conversely,  representatives from two initiatives said that current federal work on  standards duplicates existing private sector efforts, and representatives  from a third initiative expressed concern that the government is not  flexible enough to account for changing technologies and should  therefore leave this issue to the private sector. Representatives from  three initiatives we spoke with said that standards should be tested  through pilots before they are incorporated into national requirements,  and suggested that this testing of standards could be an appropriate role  for the federal government.
subsections: section_title: Variation in State Privacy Rules
paragraphs: Eleven of the 18 initiatives we selected are working to address the  challenges encountered because of variation in state privacy rules.  Representatives from 6 of these 11 initiatives said that their initiatives are  working to improve providers’ ability to obtain and track patient consent  and other patient preferences electronically. This is important because  some state privacy rules require affirmative patient consent to enable  exchange. Three of these 6 initiatives are focused on improving patients’  ability to document their consent to exchange and grant access to their  personal health information. For example, 1 initiative is developing a  framework that allows patients to document digitally whether they consent  to information sharing and to incorporate this documentation in providers’  health IT systems. Another initiative is working to enable patient control of  their information through patient-mediated exchange, which allows  patients to aggregate their health records into a PHR and electronically  grant providers access to these records according to the patient’s  preferences. Three other initiatives told us that they are using or plan to  develop technology that allows providers to share only portions of a  patient’s health record, which would allow providers to ensure that they  send only information that they are authorized to share.
Representatives from 5 of the 11 initiatives told us that their initiative  incorporated specific privacy policies into agreements signed by  participants, including policies governing patient consent and access to  their health records. For example, 1 nationwide initiative requires  participants to obtain affirmative consent from patients before their  information can be exchanged using the initiative’s product.
Representatives from several initiatives identified additional actions that  are needed to fully address this challenge. Specifically, six  representatives said that education on or federal guidance about the  application of privacy laws and liability issues would reduce confusion and  increase willingness to exchange information across state lines.  Representatives from one initiative noted that the difference between  states that require patients to affirmatively consent to sharing some or all  of their medical information and states that do not have this requirement  is a significant barrier to interoperability, though representatives from  another initiative said that this difference is less of an issue if providers  are educated in the laws of their state.
section_title: Accurately Matching Patients’ Health Records
paragraphs: Thirteen of the 18 initiatives are working to address the challenge of  accurately matching patients’ health records. Representatives from 4 of  the 13 initiatives said that their initiatives are working to improve the  quality of the data or types of information used for matching patients’  health records. For example, 2 initiatives are working to establish  standard data formats for health IT systems, which may reduce  differences in demographic data for the same patient, thus improving the  accuracy of matching. Representatives from 2 other initiatives told us that  their initiative is working to create a list of patient attributes (e.g.,  telephone number and address) that can be combined to establish a  patient’s identity with high success and enable providers and others to  match patient records as accurately as possible.
Representatives from 7 of the 13 initiatives told us that they require their  participants to use a standardized method for patient matching or are  working to develop standardized methods. For example, 1 initiative  requires that all participants incorporate the same patient-matching  method into their EHR systems. Representatives from 2 other initiatives  said that their initiative is working to reconcile variations in the data  elements and formats used for patient matching by network participants,  with the goal of adopting a single shared method among all participants.  Representatives from another initiative told us that the initiative is working  to develop a tool for matching patients to their records that can be  incorporated directly into EHR systems. Notably, 2 of the initiatives that  are working on patient-matching methods said that they rely on patients  to confirm that the match is accurate at the site-of-care. Representatives  from 1 of these initiatives noted that this approach may not be practical in  circumstances or settings in which information is required immediately or  the patient is unresponsive.
Representatives from 2 of the 13 initiatives said that they are working to  enable patient-mediated exchange, which involves allowing patients to  aggregate their health information in a PHR. One representative noted  that patients are likely to notice if their PHR contains information that is  incorrectly matched and to correct the error.
Representatives from five initiatives noted that a national patient identifier,  which HHS identifies as currently prohibited under law, is needed to fully  address this challenge.
section_title: Costs Associated with Interoperability
paragraphs: Sixteen of the 18 initiatives are working to address the challenge of the  reported high costs associated with interoperability. Some of these  initiatives are working to address this challenge using multiple  approaches. Representatives from 10 initiatives that said they are  addressing this challenge by reducing the need to customize EHR  systems to connect with other systems. For example, representatives  from 1 initiative explained that participants must adopt standard features  that should reduce the amount of customization needed to connect with  other systems. Representatives from 3 initiatives explained that they give  participants the opportunity to reduce the cost of interoperability by paying  for only one interface to connect with all the entities participating in the  initiative, instead of paying for individual connections to each entity.  Officials from 3 other initiatives told us that they are focused on creating  APIs—programming instructions that allow systems to extract data from  other systems that adopt the same API—that they said would nearly  eliminate the need to customize systems that adopt the API, or are  working to leverage APIs to create applications that can be easily added  to EHR systems to exchange and analyze interoperable data.
Representatives from 12 initiatives said that their initiatives’ products are  or will be available at no cost or at a reasonable cost to providers or  vendors. For example, representatives from 4 initiatives told us that the  profiles and specifications they are developing will be available free of  charge for vendors and providers to incorporate into EHR systems.  Representatives from 6 other initiatives said that they are attempting to  keep the cost of participation in the initiative reasonable. For example,  representatives from 1 initiative said that they adjust their fees for  different provider types to accommodate differences in the providers’ data  exchange needs, thus increasing the likelihood that providers can afford  to participate.
Representatives from three initiatives explained that they are working to  address the cost issue by creating standardized legal agreements to  govern information sharing, which can be easily adapted by initiative  participants and reduce the need for legal services and the accompanying  legal fees.
section_title: Need for Governance and Trust among Entities
paragraphs: Eleven of the 18 initiatives are working to establish governance and trust  among the entities that seek to exchange interoperable health  information. Representatives from 7 of the 11 initiatives are fulfilling the  need for governance and trust among entities by establishing standard  legal agreements that their participants adopt and use to govern  relationships within the initiative. For example, 1 initiative crafted a  publically available agreement that includes provisions related to security  and authentication policies, as well as a requirement that all participants  share patient health information openly with all other participants that are  authorized to receive this information. Another initiative has created a  committee to evaluate specific ways that the data contained in the  network may be used and incorporates these decisions into its  agreement. Another initiative deliberately designed its agreement so that  participants can also adopt existing national agreements; a representative  from this initiative noted that if there was a situation in which their  agreement conflicted with another initiative’s requirements, the initiative  would work to reconcile the conflicting requirements so its participants  could participate in both initiatives whenever possible.
Representatives from 4 of the 11 initiatives told us that they are working  to address this challenge by fostering consensus and harmonization of  policies and business practices across entities and organizations. For  example, 1 initiative facilitates consensus among different stakeholders  about methods to enable interoperability for certain uses, and releases  the results of these discussions publically for other entities to incorporate  into their agreements, policies, and practices.
section_title: Initiative Representatives Identified Other Issues That Need to be Addressed to Move Nationwide EHR Interoperability Forward
paragraphs: In addition to the five challenges identified by stakeholders and initiative  representatives, representatives identified two other issues that need to  be addressed in order to move nationwide interoperability forward.
EHR interoperability would move forward once providers saw a value  in their systems becoming interoperable. Six initiative representatives  said that improvements to EHR systems—such as enhancements that  improve providers’ workflow or clinical decision-making—are needed  to increase the extent to which an EHR system, and the information  contained within it, is a valuable tool for health care providers. Six  initiative representatives noted that reforms that tie payment to quality  of care rather than number of services provided will incentivize  sharing of information across providers to improve efficiency.
Changes to CMS’s Medicare and Medicaid EHR Incentive Programs  would also help move nationwide interoperability forward. While   8 initiative representatives we spoke with told us that the EHR  Incentive Programs have increased adoption of EHRs,  representatives from 5 initiatives suggested pausing or stopping the  programs. Representatives from 10 of the initiatives noted that efforts  to meet the programs’ requirements divert resources and attention  from other efforts to enable interoperability. For example, some  initiative representatives explained that the EHR programs’ criteria  require EHR vendors to incorporate messaging capabilities into EHR  systems, but this capability generally does not enable interoperability  at this time. Representatives from 10 of the initiatives said that the  criteria currently used to certify EHR systems under the EHR  Incentive Programs are not sufficient for achieving interoperability,  and representatives from 3 initiatives suggested amending the criteria  to focus on testing systems’ ability to interoperate.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS for comment. HHS provided  technical comments, which we incorporated as appropriate.
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, the Administrator of CMS, the National Coordinator  for Health Information Technology, appropriate congressional  committees, 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 staffs have any questions about this report, please contact  me at (202) 512-7114 or at kohnl@gao.gov. Contact points for our Office  of Congressional Relations and Office of Public Affairs can be found on  the last page of this report. Other major contributors to this report are  listed in appendix II.
section_title: Appendix I: Selected Nonfederal Initiatives GAO Reviewed
paragraphs: We identified nonfederal organizations that have ongoing initiatives that  are working to facilitate electronic health record (EHR) interoperability.  The 18 initiatives we selected for our work are listed below.
California Association of Health Information Exchanges (CAHIE)
Center for Medical Interoperability (C4MI)
ConCert by Healthcare Information and Management Systems  Society (HIMSS) eHealth Initiative (eHI)
Electronic Healthcare Network Accreditation Commission (EHNAC)
Healthcare Services Platform Consortium (HSPC)
Identity Ecosystem Steering Group (IDESG) Healthcare Committee  Integrating the Healthcare Enterprise (IHE) USA
Kansas Health Information Network (KHIN)
National Association for Trusted Exchange (NATE)
Open ID Health Relationship Trust (HEART) Working Group
Statewide Health Information Network of New York (SHIN-NY)
Substitutable Medical Applications and Reusable Technologies  (SMART) on Fast Healthcare Interoperability Resources (FHIR)
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Tom Conahan, Assistant  Director; A. Elizabeth Dobrenz; Krister Friday; Monica Perez-Nelson;   and Andrea E. Richardson made key contributions to this report.