Health Information Technology: HHS Is Pursuing Efforts to Advance Nationwide Implementation, but Has Not Yet Completed a National Strategy
Published: 2008-02-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Health information technology (IT) offers promise for improving patient safety and reducing inefficiencies. Given its role in providing health care in the United States, the federal government has been urged to take a leadership role to improve the quality and effectiveness of health care, including the adoption of IT. In April 2004, President Bush called for widespread adoption of interoperable electronic health records within 10 years and issued an executive order that established the position of the National Coordinator for Health Information Technology within the Department of Health and Human Services (HHS). The National Coordinator, appointed in May 2004, released a framework for strategic action two months later. In late 2005, HHS also awarded several contracts to address key areas of health IT. GAO has been reporting on the department's efforts toward nationwide implementation of health IT since 2005. In prior work, GAO recommended that HHS establish detailed plans and milestones for the development of a national health IT strategy and take steps to ensure that its plans are followed and milestones met. For this testimony, GAO was asked to describe HHS's efforts to advance the use of health IT. To do this, GAO reviewed prior reports and agency documents on the current status of relevant HHS activities.
section_title: What GAO Found
paragraphs: HHS and the Office of the National Coordinator have been pursuing various activities in key areas associated with the President's goal for nationwide implementation of health IT. In 2005, the department established the American Health Information Community, a federal advisory committee, to help define the future direction of a national strategy for health IT and to make recommendations to the Secretary of Health and Human Services for implementing interoperable health IT. The community has made recommendations directed toward key areas of health IT, including the expansion of electronic health records, the identification of standards, the advancement of nationwide health information exchange, the protection of personal health information, and other related issues. Even though HHS is undertaking these various activities, it has not yet developed a national strategy that defines plans, milestones, and performance measures for reaching the President's goal of interoperable electronic health records by 2014. In 2006, the National Coordinator for Health Information Technology agreed with GAO's recommendation that HHS define such a strategy; however, the department has not yet done so. Without an integrated national strategy, HHS will be challenged to ensure that the outcomes of its various health IT initiatives effectively support the President's goal for widespread adoption of interoperable electronic health records.

section_title: Letter
paragraphs: I am pleased to be here today to comment on federal efforts to  advance the use of information technology (IT) for health care  delivery. As we and others have reported, the use of IT has great  potential to help improve the quality of health care and is critical to  improving the performance of the U.S. health care system.
Recognizing the potential value of IT in public and private health  care systems, the federal government has, for several years, been  working to promote the nationwide use of health IT. In April 2004,  President Bush called for widespread adoption of interoperable  electronic health records within 10 years and issued an executive  order that established the position of the National Coordinator for  Health Information Technology within the Department of Health  and Human Services (HHS). The National Coordinator’s  responsibilities include the development and implementation of a  strategic plan to guide the nationwide implementation of  interoperable health IT in both the public and private sectors.
Since 2005, we have been reporting on the efforts of the Office of  the National Coordinator to develop and implement a national  health IT strategy. At your request, my testimony today will describe   HHS’s ongoing efforts to complete certain key health IT-related  activities. We conducted our work in support of this testimony  during February 2008. To prepare this statement, we reviewed our  prior reports and analyzed agency documents on the current status  of relevant HHS activities. All work on which this testimony is based  was performed in accordance with generally accepted government  auditing standards.
subsections: section_title: Background
paragraphs: Studies published by the Institute of Medicine and others have  indicated that fragmented, disorganized, and inaccessible clinical  information adversely affects the quality of health care and  compromises patient safety. In addition, long-standing problems  with medical errors and inefficiencies increase costs for health care  delivery in the United States. With health care spending in 2006  reaching almost $2.1 trillion, or 16 percent of the gross domestic  product, concerns about the costs of health care continue, and many  policy makers, industry experts, and medical practitioners contend  that the U.S. health care system is in a crisis.
Health IT offers promise for improving patient safety and reducing  inefficiencies. The expanded use of health IT has great potential to  improve the quality of care, bolster the preparedness of our public  health infrastructure, and save money on administrative costs. For  example, as we reported in 2003, a 1,951-bed teaching hospital  reported that it had realized about $8.6 million in annual savings by  replacing outpatient paper medical charts with electronic medical  records. This hospital also reported saving more than $2.8 million  annually by replacing its manual process for managing medical  records with an electronic process to provide access to laboratory  results and reports. Technologies such as electronic health records  and bar coding of certain human drug and biological product labels  have been shown to save money and reduce medical errors. Health  care organizations also reported that IT contributed other benefits,  such as shorter hospital stays, faster communication of test results,  improved management of chronic diseases, and improved accuracy  in capturing charges associated with diagnostic and procedure  codes. However, according to HHS, only a small number of U.S.  health care providers have fully adopted health IT due to significant  financial, technical, cultural, and legal barriers, such as a lack of  access to capital, a lack of data standards, and resistance from  health care providers.
subsections: section_title: Federal Government’s Role in Health Care
paragraphs: According to the Institute of Medicine, the federal government, as a  regulator, purchaser, health care provider, and sponsor of research,  education, and training, has a central role in shaping nearly all  aspects of the health care industry. According to the Centers for  Medicare and Medicaid Services, several federal health care  programs, such as Medicare and Medicaid, spent almost $450 billion  on health services in 2006, accounting for 23 percent of the nation’s  health care expenditures that year. Given the level of the federal  government’s participation in providing health care, it has been  urged to take a leadership role in driving change to improve the  quality and effectiveness of medical care in the United States,  including an expanded adoption of IT.
In an effort to leverage the federal government’s role in health care,  the President called for the Secretary of Health and Human Services  to appoint a National Coordinator for Health Information  Technology. The Secretary appointed the first National Coordinator  in May 2004. Two months later, HHS released a framework  document as the first step toward the development of a national  strategy; the framework described goals for achieving nationwide  interoperability of health IT and actions to be taken by both the  public and private sectors to implement a strategy for reaching  these goals.
In 2005, the Secretary formed the American Health Information  Community, a federally chartered commission, to advise the  department on achieving its goals in this area: in particular,  developing interoperable health information exchange through a  future Nationwide Health Information Network and providing most  Americans with access to secure electronic health records by 2014.  The community is made up of representatives from both the public  and private health care sectors. In 2005, it identified components of  health care that could potentially achieve measurable results in two  to three years, including electronic health records. The community  makes recommendations to the Secretary for advancing  interoperability in these areas, along with recommendations  directed toward the identification of health IT standards, the  advancement of nationwide health information exchange, the  protection of personal health information, and other related issues.  Additionally, in furtherance of the federal government’s initiative to  achieve expanded health IT adoption, in August 2006 President Bush  issued an executive order calling for federal health care programs  and their providers, plans, and insurers to use IT interoperability  standards recognized by HHS.
From its establishment in 2004 through 2008, the Office of the  National Coordinator has received about $200 million in funding to  support new efforts to ensure the adoption of health IT nationwide  through the development of data standards and the implementation  of projects on priority areas identified by the American Health  Information Community. For the first 2 years of its operation (fiscal  years 2004 and 2005), funding was provided from departmental  discretionary funds allocated by the Secretary of Health and Human  Services, and in fiscal year 2005 the office received $20 million. In  fiscal year 2006, the department began submitting budget requests  for the office. Table 1 shows the department’s requested and actual  budget for the office for fiscal years 2006 through 2008 and the  amount requested for fiscal year 2009.
HHS’s overall departmental budget request for health IT for fiscal  year 2009 is almost $115 million for various new and continuing  initiatives within multiple HHS divisions. Besides the $66 million for  the initiatives of the Office of the National Coordinator, this amount  includes   ●  $3.8 million to fund the second year of a project at the Centers for  Medicare and Medicaid Services that provides financial incentives to  physician practices to adopt certified electronic health record  systems, and   ●  $45 million for the Agency for Healthcare Research and Quality to  fund health IT investments aimed at enhancing patient safety.
The budget request also supports the continuation of an electronic  health record system for all direct health care sites of the Indian  Health Service.
Since the Office of the National Coordinator has been funded,  congressional interest in the expansion of health IT has increased.  According to the Healthcare Information Management Systems  Society, 41 pieces of legislation related to health IT were  introduced by the 109th Congress, and, so far, the 110th Congress has  introduced about 12 bills, reports, and resolutions; subjects  addressed include grants and financial assistance to help support  the implementation of health IT, provisions for incentives to health  care providers for IT implementation, standards for exchanging  health information, and protection of privacy and security of  electronic health information. Additionally, in his 2008 State of the  Union address, President Bush called for the 110th Congress to  expand the use of health IT.
section_title: Our Past Work Has Reviewed HHS’s Efforts to Define a National Strategy and Expand the Implementation of Health IT
paragraphs: Since 2005, we have reported and testified on HHS’s efforts to define  a national strategy for achieving widespread implementation of  health IT, including an approach for ensuring the protection of  electronic personal health information. We reported that through  the Office of the National Coordinator for Health IT, HHS has taken  a number of actions to promote the acceleration of the use of IT in  the health care industry. For example, in late 2005 the National  Coordinator’s Office awarded several contracts to address a range  of activities important for expanding the implementation of health  IT; these activities include  ●  defining criteria and a process for certifying the interoperability of  electronic health records to help increase the number of health care  providers adopting electronic health records,   ●  defining health information standards needed to ensure the  interoperability of electronic health records and health IT systems,   ●  defining requirements for exchanging health information throughout  a nationwide health information network, and   ●  defining privacy and security policies to ensure the protection of  electronic personal health information.
In our previous work, we reported that although HHS had made  progress in these areas, it still lacked an overall implementation  strategy, including the detailed plans, milestones, and performance  measures needed to ensure that the outcomes of its efforts are  integrated and that the President’s goals for the implementation of  nationwide health IT are met. In May 2005, we recommended that  HHS establish detailed plans and milestones for the development of  a national health IT strategy and take steps to ensure that its plans  are followed and milestones are met. We reiterated this  recommendation in March 2006 and again in September 2006.
We have also reported on HHS’s efforts to ensure the privacy of  personal health information exchanged within health information  exchange networks. According to our work, although HHS had  initiated several activities to help ensure the protection of health  information, it had not defined an overall approach for health  information privacy or an implementation strategy that included key  elements such as timelines and milestones for completing its  privacy-related initiatives. We recommended that HHS define and  implement an overall privacy approach that identifies milestones for  integrating the outcomes of its initiatives, ensures that key privacy  principles are fully addressed, and addresses challenges associated  with the nationwide exchange of health information.
section_title: HHS Is Pursuing Efforts to Advance the Nationwide Implementation of Health IT, but It Has Not Yet Completed a National Strategy
paragraphs: HHS and the Office of the National Coordinator have been pursuing  various efforts to implement health IT solutions. Among other  activities, the department has been relying on recommendations of   the American Health Information Community to assist the office’s  health IT initiatives in several key areas aimed at the expansion of  electronic health records, identification of health IT standards,  advancement of nationwide health information exchange, protection  of personal health information, and other related issues. In this  regard, HHS and the Office of the National Coordinator have taken  actions in the areas of electronic health records, standardization,  networking and information exchange, and health information  privacy and security:  Electronic health records. To help expand the implementation of  electronic health records, among other actions, HHS issued a  contract for the Compliance Certification Process for Health IT.  This contract, awarded to the Certification Commission for Health  IT, is to define criteria and a certification process to ensure that  various electronic health records products can be exchanged among  different systems in health information exchange networks. In May  2006, HHS finalized a process and criteria for certifying the  interoperability of outpatient electronic health records and  described criteria for future certification requirements. Certification  criteria for inpatient electronic health records were finalized in June  2007. To date, the Certification Commission has certified about 100  products offering electronic health records. The results of this effort  are intended to help encourage health care providers to implement  electronic health records by providing assurance that they will be  able to use electronic records effectively and exchange them with  other health IT systems.
Standardization. Through a contract for the Standards  Harmonization Process for Health IT, HHS is promoting the  implementation of standards required to enable the exchange of  electronic health information in federal health care programs, as  well as ensure the interoperability of electronic health records and  IT systems. Such standards are essential for the development of a  nationwide health information network.
The contractor, in collaboration with the National Institute for  Standards and Technology, selected initial standards to address  specific areas identified by the American Health Information  Community. These standards address, among other things,  requirements for message and document formats, along with  technical network requirements. According to the contractor, the  Secretary announced the recognition of these standards in January  2008 after a year-long period of review and testing by healthcare  providers, government agencies, consumers and other stakeholders.  Federal agencies that administer or sponsor federal health programs  are now required to implement these standards, in accordance with  President Bush’s August 2006 Executive Order.
Networking and information exchange. The Office of the National  Coordinator has taken steps to enable health care entities—such as  providers, hospitals, and clinical labs—to exchange electronic  health information on a nationwide basis. HHS has awarded  Nationwide Health Information Network contracts that were  designed to provide prototypes of national networks of health  information exchanges. These exchanges are intended to connect  providers and patients from different regions of the country and  enable the sharing of electronic health information, such as health  records and laboratory results. Together, these connections are  intended to form the “network of networks” that is envisioned to be  the Nationwide Health Information Network.
According to HHS, in early 2007 its contractors delivered final  prototypes that could form the foundation of a nationwide network  for health information exchange. In October 2007, the Secretary of  Health and Human Services announced the award of contracts  totaling $22.3 million to nine regional and state health information  exchanges to begin trial implementations of the Nationwide Health  Information Network. At the end of the first contract year— September 2008—HHS intends for the nine organizations and the  federal agencies that provide health care services to test their ability  to work together and to demonstrate real-time information  exchange based upon nationwide health information exchange  specifications that they define. HHS plans to place these  specifications and related testing materials in the public domain, so  that they can be used by other health information exchange  organizations to guide their efforts to adopt interoperable health IT.
Health information privacy and security. HHS has taken steps to  further address privacy and security issues associated with the  nationwide exchange of personal health information. In June 2007,  HHS reported the outcomes of its privacy and security solutions  contract based on the work of 34 states and territories that  participated in the contract. A final summary report described  variations among organization-level business practices, policies, and  laws for protecting health information that could affect  organizations’ abilities to exchange data. As a result of this work,  HHS developed and made available to the public a toolkit to guide  health information exchange organizations in conducting  assessments of business practices, policies, and state laws that  govern the privacy and security of health information exchange.
Additionally, in discussions with us in June 2007, the National  Coordinator for Health IT agreed with the need for an overall  approach to protect health information and stated that the  department was initiating steps to address our recommendation that  HHS define and implement an overall privacy approach. Such an  approach should be part of a comprehensive national strategy for  health IT and should include milestones for integrating the  outcomes of HHS’s various privacy-related initiatives, ensure that  key privacy principles are fully addressed, and address challenges  associated with the nationwide exchange of health information.  However, our recommendation for protecting health information  has not yet been implemented.
Further, although HHS has initiated specific activities intended to  meet the goals of its framework for strategic action, and it is  continuing efforts to expand the nationwide implementation of  health IT, it is undertaking these activities without a comprehensive  national strategy that includes the detailed plans, milestones, and  performance measures needed to ensure that the outcomes of its  various initiatives are integrated and its goals are met. Given the  many activities to be coordinated, such a national strategy is  essential.
The National Coordinator acknowledged in March 2006 that more  detailed plans were needed for the office’s various initiatives and  told us that HHS intended to release a strategic plan with detailed  plans and milestones in late 2006. Nonetheless, today the office still  lacks the detailed plans, milestones, and performance measures that  are needed. According to its fiscal year 2009 performance plans, the  Office of the National Coordinator has prepared a draft health IT  strategic plan, which it intends to release in the second quarter of  2008. If properly developed and implemented, this strategy should  help ensure that HHS’s various health IT initiatives are integrated  and effectively support the goal of widespread adoption of  interoperable electronic health records.
In summary, Mr. Chairman, our work shows that the Office of the  National Coordinator for Health Information Technology has been  undertaking important work on specific activities supporting the  goals of its framework for strategic action. However, HHS has not  yet defined detailed plans and milestones for integrating the various  initiatives, nor has it developed performance measures for tracking  progress toward the President’s goal for widespread adoption of  interoperable electronic health records by 2014. To its credit, the  office has taken steps to advance electronic health record adoption,  identify interoperability standards, enable nationwide health  information exchange, and protect personal health information.  However, given the amount of work yet to be done and the complex  task of integrating the outcomes of HHS’s various initiatives, it is  essential that a national strategy for health IT be defined that  includes plans, milestones, and performance measures for ensuring  progress toward the President’s goals. Without such a strategy, it is  difficult to gauge the amount of progress being made by HHS toward  achieving widespread adoption of interoperable electronic health  records by 2014.
Mr. Chairman, this concludes my statement. I would be pleased to  answer any questions that you or other Members of the Committee  may have.
section_title: Contacts and Acknowledgments
paragraphs: If you should have any questions about this statement, please  contact me at (202) 512-6304 or by e-mail at melvinv@gao.gov. Other  individuals who made key contributions to this statement are  Barbara S. Collier, Amanda C. Gill, Nancy E. Glover, M. Saad Khan,  and Teresa F. Tucker.
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