Health Care: National Strategy Needed to Accelerate the Implementation of Information Technology
Published: 2004-07-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Health care is an information-intensive industry that remains highly fragmented and inefficient. Hence, the uses of information technology (IT)--in delivering clinical care, performing administrative functions, and supporting the public health infrastructure--have the potential to yield both cost savings and improvements in the care itself. In 2003, GAO reported on benefits to health care that could result from using IT--both cost savings and measurable improvements in the delivery and quality of care. GAO also reported on federal agencies' existing and planned information systems intended to support our nation's preparedness for and ability to respond to public health emergencies and the status of health care standards setting initiatives. Congress has asked GAO to summarize our work on reported benefits of the use of IT for health care delivery and on IT initiatives supporting public health preparedness and response.
section_title: What GAO Found
paragraphs: The use of IT can yield benefits in clinical care and associated administrative functions as well as in public health. Health care organizations reported that electronic medical records (EMR) improved the delivery of care because, among other reasons, more complete medical documentation was available to support the provider's diagnosis. In addition, EMRs could greatly facilitate the reporting of public health information associated with the early detection of and response to disease outbreaks. One hospital replaced outpatients' paper medical charts with EMRs, realizing about $8.6 million in annual savings. This hospital also established electronic access to laboratory results and reports, replacing its manual process for handling medical records and saving another $2.8 million a year. In addition, the lessons learned that were reported to us by health care organizations that have successfully implemented solutions could be used by other organizations to accelerate the adoption of health IT. These lessons recognize the importance of reengineering business processes, gaining users' acceptance of IT, providing adequate training, and making systems secure. Regarding public health, federal agencies identified 72 existing and planned information systems--34 surveillance systems, 18 supporting technologies, 10 communications systems, and 10 detection systems. For example, the Centers for Disease Control and Prevention is currently implementing its Public Health Information Network comprised of a number of disease surveillance and communications systems, including the Health Alert Network. This network is an early warning and response system that is intended to facilitate communication among federal, state, and local agencies during public health emergencies. GAO also reported that identification and implementation of health care data, communications, and security standards--which are necessary to support compatibility and interoperability of agencies' various IT systems--remained incomplete across the health care sector. To address the challenges of coordinating the many IT initiatives and implementing a consistent set of standards, GAO recommended last year that the Secretary of Health and Human Services develop a strategy for public health preparedness and response, to include setting priorities for IT initiatives and establishing mechanisms to monitor the implementation of standards throughout the health care industry. Since that time, progress has been made in identifying standards. The Office of Management and Budget's e-government initiative, the Consolidated Health Informatics initiative, has identified a number of standards to be applied to new federal development efforts and modifications of existing systems. This initiative is intended to promote the interoperability of information systems. However, implementing these standards across the federal government is still a work in progress. Until these standards are implemented, information-sharing challenges will remain. In April of this year, Executive Order 13335 established a National Health IT Coordinator and called for a strategic plan to guide the nationwide implementation of interoperable health IT. As this plan moves forward, it will be essential to have continued leadership, clear direction, measurable goals, and mechanisms to monitor progress.

section_title: Letter
paragraphs: I am pleased to be here today to discuss the benefits that effective  implementation of information technology (IT) can bring to the  health care industry.  According to the Institute of Medicine and  others, health care is an information-intensive industry that remains  highly fragmented and inefficient. Hence, the uses of IT—in  delivering clinical care, performing administrative functions, and  supporting the public health infrastructure—have the potential to  yield both cost savings and improvements in the care itself.
However, effectively implementing IT has historically been a major  challenge for this industry.  Currently there is inconsistent use of IT  in exchanging data and delivering care.  In addition, implementing  information security measures that resist cyber attacks also remains  a challenge.
At your request, today I will summarize our previously issued  reports on (1) the reported benefits of using IT for health care  delivery, including lessons learned from health care organizations  that have implemented IT and (2) IT initiatives that support the  public health infrastructure, including the status of standards setting  initiatives that are necessary to support greater information sharing.   In preparing this testimony, we summarized our prior reports and  updated progress on our recommendations in accordance with  generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: The United States health care system is a large sector of the  economy comprised of clinicians, health care delivery organizations,  insurers, consumers, and government health agencies. According to  the Medicare Payment Advisory Commission, the health care  industry generally uses less IT than other industries, and the extent  and types of IT deployed vary by setting and institution.  The health  care industry has recognized that IT can improve the quality of care,  promote patient safety, reduce costs of both care and administrative  functions, and expedite response to public health emergencies.
Public health officials are increasingly concerned about our  exposure and susceptibility to infectious disease and food-borne  illness because of global travel, increased volume of food imports,  and the evolution of antibiotic-resistant pathogens.  Public health  experts maintain that a strong infrastructure could provide the  capacity to prepare for and respond to both acute and chronic  threats to the nation’s health, whether they are bioterrorism attacks,  emerging infections, disparities in health status, or increases in  chronic disease and injury rates.
IT can play an essential role in supporting federal, state, local, and  tribal governments in public health activities and clinical care  delivery. For public health emergencies in particular, the ability to  quickly exchange data from provider to public health agency—or  from provider to provider—is crucial in detecting and responding to  naturally occurring or intentional disease outbreaks. It allows  physicians to share individually identifiable information with public  health agencies for use in performing public health activities.
The Centers for Disease Control and Prevention (CDC) has  previously acknowledged several IT limitations in the public health  infrastructure. For example, basic capability for disease surveillance  systems to detect and analyze disease outbreaks is lacking for  several reasons. First, health care providers have traditionally used  paper- or telephone-based systems to report disease outbreaks to  approximately 3,000 public health agencies. This is a labor-intensive,  burdensome process for local health care providers and public  health officials, often resulting in incomplete and untimely data.  Second, not all public health agencies have access to the Internet or  to secure channels for electronically transmitting sensitive data.
Several types of systems can play vital roles in identifying and  responding to public health emergencies, including acts of  bioterrorism.  These types of systems—described in a technology  assessment for the Department of Health and Human Services  (HHS) that was completed by the University of California San  Francisco-Stanford Evidence-based Practice Center—serve different  but related functions and include the following:
Detection—systems that consist of devices for the collection  and identification of potential biological agents from  environmental samples, making use of IT to record and send  data to a network.
Surveillance—systems that facilitate the performance of  ongoing collection, analysis, and interpretation of disease-related  data to plan, implement, and evaluate public health actions.
Diagnostic and clinical management—systems with potential  utility for enhancing the likelihood that clinicians will consider  the possibility of bioterrorism-related illness. These systems are  generally designed to assist clinicians in developing a differential  diagnosis for a patient who has an unusual clinical presentation.
Communications—systems that facilitate the secure and timely  delivery of information to the relevant responders and decision  makers so that appropriate action can be taken.
In April of this year, the President issued an Executive Order, which  recognizes the importance of IT to the improvement of the health  care system to address problems with high costs, medical errors,  and administrative inefficiencies.  The order establishes the position  of a National Health Information Technology Coordinator.  This new  position has been tasked with providing leadership for the  development and nationwide implementation of interoperable  health IT in both the public and private health care sectors.  The  President also announced a goal of having EMRs available for most  Americans within the next 10 years.
section_title: Information Technology Can Provide Benefits for Delivery of Care
paragraphs: IT can provide significant benefits in providing clinical health care  and in the administrative functions associated with health care  delivery.  Last October, we identified 20 examples of reported cost  savings or other benefits at 14 health care organizations that had  implemented IT solutions in their clinical care environments. The  rapidly rising costs of health care, along with an increasing concern  for the quality of care and the safety of patients, are driving health  care organizations to use IT to automate clinical care operations and  their associated administrative functions. IT is now being used for,  among other things, EMRs, order management, Internet access for  patient and provider communications, and automated billing and  financial management.
Health care delivery organizations identified instances that resulted  in cost savings from the use of IT as a result of reductions in costs  associated with medication errors, communication and  documentation of clinical care and test results, staffing and paper  storage, and processing of information.  Specific examples included:
A teaching hospital reported that it realized about $8.6 million in  annual savings by replacing paper medical charts with EMRs for  outpatients. It also reported saving over $2.8 million annually by  replacing its manual process for handling medical records with  electronic access to laboratory results and reports.
A teaching hospital reported that it saved $5 million annually on  drug substitutions, based on automated prompts that  recommended alternatives resulting in increased quality and  decreased cost.
A community hospital prevented the administration of over 1,200  wrong drugs or dosages and almost 2,000 early or extra doses by  using bar code technology and wireless scanners to verify both  the identities of patients and their correct medications. The  reported monetary value of the errors prevented was almost  $850,000.
An integrated health care delivery organization reduced the  overall number of daily chart pulls, estimating that about $5.7  million in medical record staffing costs were avoided or saved  annually.
IT also contributed to other benefits, such as shorter hospital stays,  faster communication of test results, improved management of  chronic disease, and improved accuracy in capturing charges  associated with diagnostic and procedure codes. For example,
A teaching hospital reported a decrease in average length of stay  from 7.3 to 5 days when it implemented an integrated EMR  system that resulted in improvements in health care efficiency  and practice changes.
A teaching hospital reported improved patient scheduling using a  rules-based electronic scheduling system that accommodated  travel time to the appointment, fasting requirements, and  providers’ availability.
An integrated health care delivery organization reported  improvements in diabetes control for members with the disease,  decreases in upper gastrointestinal studies ordered, and  increases in the number of Pap smears performed by using alerts  and reminders, automated patient care guidelines, and data  warehouse reports.
A teaching hospital reported that 4 percent of radiology orders  that had been entered into the order entry system were cancelled  and 55 percent were changed when an embedded alert warned  that an order was inappropriate for specified clinical reasons.
Health care organizations also told us that EMRs could also improve  the delivery of care because, among other reasons, more complete  medical documentation was available to support the provider’s  diagnosis.  In addition, EMRs greatly facilitate the reporting of  public health information associated with the early detection of and  response to disease outbreaks.
The lessons learned that were reported to us by health care  organizations that have successfully implemented IT may prove  useful for other organizations as they implement solutions—such as  recognizing the importance of reengineering business processes,  gaining users’ acceptance, providing adequate training, and making  systems available and secure.  For example, organizations reported  that business process changes were key in effectively implementing  the technology and that users, including physicians, should be  involved in systems design and implementation.
section_title: Many IT Initiatives Address the Public Health Infrastructure, Although Standards Implementation Challenges Remain
paragraphs: In May 2003, we reported that six federal agencies involved in  bioterrorism preparedness and response had a large number of  existing and planned information systems associated with  supporting a public health emergency.  Specifically, these agencies  identified 72 information systems and supporting technologies.  Of  the 72 systems, 34 are surveillance systems, 18 are supporting  technologies, 10 are communications systems, and 10 are detection  systems.  In spite of these many initiatives, the key ones that are  intended to facilitate greater information sharing are still being  developed and implemented.  For example, CDC is currently  implementing its Public Health Information Network, which  consists of a number of disease surveillance and communications  systems, including the Health Alert Network.  This network is an  early warning and response system intended to provide federal,  state, and local agencies with better communications during public  health emergencies.  The Department of Defense is using its  Electronic Surveillance System for the Early Notification of  Community-based Epidemics (ESSENSE) to support early  identification of infectious disease outbreaks in the military by  comparing analyses of data collected daily with historical trends.   We also found that agencies varied in the extent to which they  interacted and coordinated with other agencies in planning and  operating each of these initiatives.
The October 2001 anthrax attacks and the subsequent emergence of  new infectious diseases have highlighted the importance of data  standards for real-time data exchange across the public health  infrastructure.  During the anthrax attack, participants accumulated  dissimilar data and principally exchanged it manually.
Since 1993, we have called for federal leadership to expedite the  standards development process in order to accelerate the use of  EMRs.  Most recently, in May 2003, we again reported that the  identification and implementation of health care data,  communications, and security standards—which are necessary to  support the compatibility and interoperability of agencies’ various  IT systems—remains incomplete across the health care industry.   We also identified other standards setting initiatives (e.g., CHI and  HIPPA) and raised concerns about coordinating these initiatives.
To address the challenges of coordinating the many IT initiatives  and implementing a consistent set of standards, we recommended  that the Secretary of Health and Human Services (HHS), in  coordination with other key stakeholders, establish a national IT  strategy for public health preparedness and response, including  specific steps toward improving the nation’s ability to use IT in  support of the public health infrastructure.  Specifically, we  recommended, among other things, that the Secretary set priorities for information systems, supporting technologies,  and other IT initiatives; define activities for ensuring that the various standards-setting  organizations coordinate their efforts and reach further  consensus on the definition and use of standards; establish milestones for defining and implementing all standards; create a mechanism—consistent with HIPAA requirements—to  monitor the implementation of standards throughout the health  care industry.
Since our May 2003 report, HHS has continued its efforts to identify  applicable standards throughout the health care industry and across  federal health care programs.  For example, in May 2004, the CHI  initiative—one of OMB’s e-government projects—announced fifteen  additional standards that build on the initial five announced in  March 2003.  Federal agencies are expected to include the standards  in their architectures and when they build, acquire, or modify  systems.  Current plans for the CHI initiative call for it to be  incorporated into HHS’s Federal Health Architecture by September  2004.  This architecture is still evolving, and many issues—such as  coordination of the various standards setting efforts and  implementation of the standards that have been identified—are still  works in progress.  Until these standards are more fully  implemented, federal agencies and others associated with the public  health infrastructure cannot ensure that their systems will be  capable of exchanging data with other systems when needed and  consequently cannot ensure effective preparation for and response  to public health emergencies, including acts of bioterrorism.
In addition, in April of this year, the President issued an Executive  Order, which calls for the establishment of a National Health  Information Technology Coordinator and the issuance of a broader  strategic plan to guide the nationwide implementation of  interoperable health care information systems.  The coordinator is  also specifically tasked with creating incentives for the use of health  IT and accelerating the adoption of EMRs, among other things.  The  Coordinator plans to present the strategic plan next week.  Such a  plan, if properly crafted, should help to move the health care  industry towards interoperable information systems.  As health IT  initiatives are pursued, it will be essential to have continued  leadership, clear direction, measurable goals, and mechanisms to  monitor progress.
In summary, there are many opportunities and challenges associated  with the implementation of IT for clinical care delivery and public  health.  The federal government, namely HHS, has taken a  leadership role in establishing a strategy and identifying data and  communications standards, which are critical for sharing data  across the health care industry—both to improve the quality of  patient care in the United States and to strengthen the public health  infrastructure.  However, much more work remains to more fully  utilize IT for the delivery of care and to identify and respond to  public health emergencies.  HHS needs to provide continued  leadership, sustained and focused attention, clear direction, and  mechanisms to monitor progress in order to bring about measurable  improvements and achieve the President’s goals.
Mr. Chairman, this concludes my statement. I would be happy to  answer any questions that you or members of the subcommittee  may have at this time.
If you should have any questions about this testimony, please  contact me at (202) 512-9286 or M. Yvonne Sanchez, Assistant  Director, at (202) 512-6274. We can also be reached by e-mail at  pownerd@gao.gov and sanchezm@gao.gov, respectively.  Other  individuals who made key contributions to this testimony include  Joanne Fiorino, M. Saad Khan, and Mary Beth McClanahan.
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