Electronic Health Records: HHS Strategy to Address Information Exchange Challenges Lacks Specific Prioritized Actions and Milestones
Published: 2014-03-24T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Health Information Technology for Economic and Clinical Health Act (HITECH) promotes the use of health information technology and identifies the importance of health information exchange. It provides incentive payments to promote the widespread adoption and meaningful use of EHR technology. To be a meaningful user, providers are to demonstrate, among other things, that their certified EHR technology can electronically exchange health information. GAO examined (1) the key challenges to the electronic exchange of health information, if any, that have been reported by providers and stakeholders, and HHS's ongoing efforts to address them, and (2) the extent to which HHS has planned future actions to address those key challenges. GAO reviewed HHS documentation; interviewed HHS officials; and interviewed providers—hospital officials and physicians—and relevant stakeholders about their experiences.
section_title: What GAO Found
paragraphs: Providers and stakeholders GAO interviewed in four states with ongoing electronic health information exchange efforts cited key challenges to exchange, in particular, issues related to insufficient standards, concerns about how privacy rules can vary among states, difficulties in matching patients to their records, and costs associated with exchange. Officials from the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC)—agencies within the Department of Health and Human Services (HHS)—noted that they have several ongoing programs and initiatives to help address some aspects of these key challenges, but concerns in these areas continue to exist. For example, several providers GAO interviewed said that they have difficulty exchanging certain types of health information due to insufficient health data standards. Although HHS has begun to address insufficiencies in standards through its Medicare and Medicaid Electronic Health Record (EHR) programs, such as through the introduction of new 2014 standards for certified EHR technology, it is unclear whether its efforts will lead to widespread improvements in electronic health information exchange. In addition, providers GAO interviewed reported challenges covering costs associated with electronic exchange, such as upfront costs associated with purchasing and implementing EHR systems. While HHS is working to address this challenge through various efforts, including a program that helps fund health information exchange organizations—organizations that provide support to facilitate the electronic exchange of health information—some providers told GAO they do not participate in these organizations because they see limited opportunities for exchanging information through them.
HHS, including CMS and ONC, developed and issued a strategy document in August 2013 that describes how it expects to advance electronic health information exchange. The strategy identifies principles intended to guide future actions to address the key challenges that providers and stakeholders have identified. However, the HHS strategy does not specify any such actions, how any actions should be prioritized, what milestones the actions need to achieve, or when these milestones need to be accomplished. GAO's prior work, consistent with the Government Performance and Results Act Modernization Act of 2010 (GPRAMA), sets forth several key elements of strategies that can guide agencies in planning and implementing an effective government program. As noted in GAO's prior work, elements such as specific actions, priorities, and milestones are desirable for evaluating progress, achieving results in specified time frames, and ensuring effective oversight and accountability. Determining specific actions and exchange-related milestones with specified time frames can help to ensure that the agencies' principles and future actions result in timely improvements in addressing the key challenges reported by providers and stakeholders; this is particularly important because planning for Stage 3 of the EHR programs, which focuses on improving outcomes, is expected to begin as soon as 2014. This information could also help CMS and ONC prioritize their future actions based on whether health information is being exchanged effectively among providers, in order to better achieve the EHR programs' ultimate goals of improving quality, efficiency, and patient safety.
section_title: What GAO Recommends
paragraphs: GAO recommends that CMS and ONC (1) develop and prioritize specific actions that HHS will take consistent with the principles in HHS's strategy to advance health information exchange, and (2) develop milestones with time frames for the actions to better gauge progress toward advancing exchange, with appropriate adjustments over time. In commenting on the draft report, HHS, including CMS and ONC, concurred with these recommendations.

section_title: Letter
paragraphs: The use of health information technology (HIT), such as electronic health  record (EHR) systems, has the potential to allow health care providers  and others to exchange health care information electronically, which is a  key way that this technology could lead to improved health care quality  and reduced costs. Health information exchange is especially important  because the health care system is highly fragmented, with care and  services provided in multiple settings, such as physician offices and  hospitals, that may not be coordinated with each other. Because of this  fragmentation, providers may lack ready access to critical information  needed to, for example, coordinate the care of patients to ensure they  make the most-informed decisions on treatment options. Lack of care  coordination can lead to inappropriate or duplicative tests and procedures  that increase health care spending. Estimates of this spending increase  range from $148 billion to $226 billion per year.
To deliver coordinated care, a physician and other members of the care  team must access and share health information from multiple settings.  Providers may share clinical data using manual methods such as faxing  paper records, but these methods can be time consuming and costly and  are often unavailable at the point of care. In addition, data shared via  manual methods are generally not structured or captured electronically to  be stored in EHRs. Lacking the ability to receive and store structured data  in their systems, providers may not be able to easily search for the  information they need or electronically transmit the information effectively  to another EHR without manual efforts. Electronic health information  exchange has the potential to bring patient information directly from an  EHR to the provider delivering care, regardless of where the care or  services are delivered. Electronically exchanging information can facilitate  care coordination and improve communication among providers, staff,  and patients by making patient clinical information more readily available  to providers. Electronically exchanging information is also important in  new delivery system and payment models, such as accountable care  organizations (ACO), because of the need for providers in different  settings to have ready access to information needed to manage and  coordinate care.
HITECH was enacted as title XIII of division A and title IV of division B of the Recovery  Act. Pub. L. No. 111-5, div. A, tit. XIII, 123 Stat. 115, 226-279 and div. B, tit. IV, 123 Stat.  115, 467-496 (2009).
To be certified, EHR technology must meet certain criteria established by HHS’s Office of  the National Coordinator for Health Information Technology that describe minimum related  performance standards and implementation specifications. Certified EHR technology  helps assure purchasers and other users that an EHR offers a minimum level of  technological capability, functionality, and security. meaningful use of EHR technology and which are estimated to include  total spending of $30 billion from 2011 through 2019.
Research suggests that despite substantial growth in EHR adoption,  electronic exchanges between providers have remained limited. requires us to report on, among other things, its effect on the adoption of  EHRs by providers. We issued five reports on the EHR programs’  implementation. For example, in March 2014, we reported on the extent  to which providers have met measures of meaningful use, including  measures that involved the electronic exchange of health information, and  noted that providers may face challenges meeting some of these  measures under the EHR programs. As discussed with the committees of  jurisdiction, this report addresses the electronic exchange of health  information and serves as one of the series of reports we conducted to  respond to the mandate. Specifically, this report examines (1) the key  challenges to the electronic exchange of health information, if any, that  have been reported by providers and stakeholders, and HHS’s ongoing  efforts to address these challenges, and (2) the extent to which HHS has  planned future actions to address the key challenges, if any, reported by  providers and stakeholders.
C. DesRoches et al., “Adoption of Electronic Health Records Grows Rapidly, but Fewer  Than Half of US Hospitals Had at Least a Basic System in 2012,” Health Affairs, vol. 32,  no. 8 (2013); and M. Furukawa et al., “Hospital Electronic Health Information Exchange  Grew Substantially In 2008-12,” Health Affairs, vol. 32, no. 8 (2013). ongoing efforts to address these challenges, we selected four states— Georgia, North Carolina, Minnesota, and Massachusetts—in which to  interview selected providers and other relevant stakeholders to learn  about the exchange of health information within their respective states.  We initially interviewed selected providers in Georgia, and then selected  the additional states of North Carolina, Minnesota, and Massachusetts  because they were mentioned during interviews with stakeholders and  officials from HHS as having ongoing efforts related to health information  exchange. These three states also had an existing Pioneer ACO or a  Beacon Community in which providers were likely to have some  experience attempting to electronically exchange health information. In  each of the four selected states, we asked officials from the Regional  Extension Centers (REC) and health information exchange organizations  (HIE organization) to tell us about the exchange activities occurring in  their state and to help us identify providers—individual physicians,  hospitals, and health systems—to learn about their efforts to exchange  health information. We also conducted interviews with other relevant  stakeholders that include the American Hospital Association (AHA), the  American Medical Association, the College of Healthcare Information  Management Executives (CHIME), and two commonly used EHR vendors  for providers that attested to meaningful use in 2012. We conducted a  total of 30 interviews with providers and stakeholders. Findings based on  these interviews cannot be generalized to all providers.
In addition to interviewing providers and stakeholders about electronic  exchange and the challenges of such exchange, we also reviewed  additional sources to supplement our interviews, such as published  literature and written information provided from stakeholders such as  CHIME and AHA, including their responses to HHS’s March 2013 request  for information (RFI) about interoperability and health information  exchange. To provide context for the challenges reported by providers  and stakeholders and to identify HHS’s ongoing efforts to address them,  we interviewed officials from the Centers for Medicare & Medicaid  Services (CMS) and the Office of the National Coordinator for Health  Information Technology (ONC) and reviewed documents related to  current HHS efforts on health information exchange.
GAO, Combating Terrorism: Evaluation of Selected Characteristics in National  Strategies Related to Terrorism, GAO-04-408T (Washington, D.C.: Feb. 3, 2004).
Act (GPRAMA) of 2010.delineates its planned steps for health information exchange to these  requirements.
We compared HHS’s documentation that  We conducted this performance audit from February 2013 through March  2014 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 Information Exchange
paragraphs: Approaches to electronic health information exchange have expanded in  recent years with the increased adoption of EHRs and growth of HIE  organizations. For example, some providers can electronically exchange  clinical information via interoperable EHR systems. In cases in which  providers wish to exchange electronic health information but do not have  interoperable systems, HIE organizations can serve as key facilitators of  exchange by providing for data connections among stakeholders,  including laboratories, public health departments, hospitals, and  physicians. Specifically, the use of EHR technology and the use of HIE  organizations can allow providers to request and receive information  about patients from other providers’ records, such as medication lists,  laboratory results, or previous diagnoses and hospitalizations. For  example, when a provider requests information, the HIE organization may  be able to identify the sources of the requested data and initiate the  electronic transmission that delivers the data from another provider’s EHR  in a format that can be accepted and processed by the receiving  provider’s EHR. Examples of exchange activities that can occur using  EHR technology directly between providers or through an HIE  organization are shown in figure 1.
According to an April 2012 article, exchanging EHR information with other  entities can be significantly more difficult for a provider than using EHRs  to manage health information within the provider’s organization only— without exchanging the information with others. Appendix I provides  information about the extent to which providers are able to electronically  exchange health information, as reported by providers and stakeholders  we interviewed.
section_title: Medicare and Medicaid EHR Programs
paragraphs: HITECH provided funding for various activities, including the Medicare  and Medicaid EHR programs. These programs are intended to help  increase the meaningful use of EHR technology by providing incentive  payments for, and later imposing penalties on, providers—that is, certain  hospitals and health care professionals such as physicians—who  participate in Medicare or Medicaid. These programs are the largest of  the activities, in terms of potential federal expenditures, funded by  HITECH. Within HHS, CMS and ONC have developed the programs’  requirements.
As the programs progress through these stages,
Stage 1, which began in 2011, set the basic functionalities EHRs must  include, such as capturing data electronically and providing patients  with electronic copies of health information. CMS and ONC indicated that Stage 1 allowed providers to test the capability of their  EHRs to electronically exchange health information.
Stage 2, which began in 2014, added requirements such as increased  health information exchange between providers to improve care  coordination for patients. For example, Stage 2 will require hospitals  and professionals to provide an electronic summary of care document  for each transition of care or referral to another provider, whereas in  Stage 1 this measure was optional.
Stage 3, which is scheduled to go into effect in 2017, will continue to  expand on meaningful use to improve health care outcomes and the  exchange of health information, according to CMS and ONC. The  requirements for this stage have not yet been developed.
ONC is responsible for identifying health data standards and technical  specifications for EHR technology and establishing and overseeing the  certification of EHR technology. As part of the EHR programs, providers  must report annually on certain mandatory meaningful use measures and  on additional measures that they may choose from a menu of measures.  Appendix II describes those Stage 1 and Stage 2 meaningful use  measures that CMS and ONC reported as specifically relating to health  information exchange.
section_title: Challenges Are Reported Related to Standards, Privacy, Patient Matching, and Costs of Electronic Exchange
paragraphs: Providers and stakeholders we interviewed cited key challenges to  electronic health information exchange; in particular, they cited issues  related to insufficient standards, concerns about how privacy rules can  vary among states, difficulties in matching patients to their records, and  costs associated with electronic health information exchange. CMS and  ONC officials noted that they have several ongoing programs and  initiatives to help address some aspects of these key challenges, but  concerns in these areas continue to exist.
Reported insufficiencies in standards for electronic health  information exchange. While standards for electronically exchanging  information within the EHR programs exist, providers reported that  standards may not be sufficient in some areas. Information that is  electronically exchanged from one provider to another must adhere to the  same standards in order to be interpreted and used in EHRs, thereby  permitting interoperability. Several providers stated that they often have  difficulty exchanging certain types of health information with other  providers that have a different EHR system due to a lack of sufficient  standards to support exchange.
One area for which providers told us standards were insufficient relates to  standards for allergies. Specifically, one provider noted that there are not  sufficient standards to define allergic reactions, and another provider  explained that some EHR systems classify an allergic reaction as a side  effect, while other EHR systems classify the same reaction as an allergy.  Such differences can cause confusion when health information is  exchanged among providers because providers who receive information  may have difficulty locating or using information on allergies if their EHR  systems classify the information differently than the EHR systems of the  providers who sent the information. Similarly, an article from the Journal  of the American Medical Informatics Association stated that the proper  terminology for encoding patients’ allergies is complex and that some  gaps still exist across existing standards.
Providers who participated in the EHR programs from fiscal year 2011 through fiscal  year 2013 could use certified EHR technology that conformed to the 2011 edition of the  standards and certification criteria. All providers that participate in the EHR Programs in  fiscal year 2014 must conform to the 2014 edition of the standards and certification  criteria. ONC is expected to develop another set of standards and certification criteria that  certified EHR technology would be required to conform to beginning in 2016. from one entity to another. HHS expects that providers using the 2014  edition will have greater ability to exchange information.
Patient encounters are commonly recorded in free-form text narratives, or as  unstructured clinical data. While free-form patient narratives give the provider flexibility to  note observations that are not supported by structured data, they are not easily  searchable and aggregated and can be more difficult to analyze. that RxNorm and the Systematized Nomenclature of Medicine Clinical  Terms (SNOMED CT) should be expanded for nonmedication allergies  and allergic reactions. Fifth, several providers and stakeholders  commented that the Direct Protocol allows for limited exchange, such as  exchanging a secure email message, rather than enabling certain other  functionalities, such as the ability to query another EHR system.
Reported variation in state privacy rules and lack of clarity about  requirements. Some providers noted that exchanging health information  with providers in other states can be difficult due to their limited  understanding of variations in privacy rules from state to state. Some  providers also noted that exchange can be especially difficult in cases  when providers are located close to state borders and therefore serve  patients from another state. Providers that are covered by the Health  Insurance Portability and Accountability Act (HIPAA) of 1996 must adhere  to federal privacy rules and can also be subject to state privacy rules. These state rules can be more stringent than HIPAA requirements or  standards.
HIPAA’s Administrative Simplification Provisions required the establishment of, among  other things, national privacy standards. Pub. L. No. 104-191, Title II, Subtitle F, 110 Stat.  1936, 2021 (codified at 42 U.S.C. §§ 1320d–1320d-8). These provisions also expressly  provided that such national standards would not preempt state laws that impose  requirements, standards, or implementation specifications that are more stringent than  those imposed under federal regulation. Pub. L. No. 104-191, Title II, Subtitle F, 110 Stat.  1936, 2021, see 42 U.S.C. §§ 1320d–2 notes. HIPAA regulates covered entities’  (including most health care providers’) use and disclosure of personal health information.  The Privacy Rule generally permits the use or disclosure of an individual’s protected  health information without the individual’s written authorization for purposes of treatment,  payment and health care operations. Under the Privacy Rule, more stringent state laws  that are not preempted by federal law include those that prohibit or restrict a use or  disclosure in circumstances under which such use or disclosure would be permitted under  HIPAA. See 45 C.F.R. 160.202.
To address privacy issues related to electronic health information  exchange, ONC officials have several ongoing efforts. For example, ONC  has issued high-level guidance for providers on how to ensure the privacy  and security of health information covering a wide range of topics related  to meaningful use and the HIPAA Privacy and Security Rules, among  other things. Regarding state privacy laws, this guidance suggests that  providers seek information from state agencies, RECs, and professional  associations to understand how state laws affect the sharing of patient  health information. In addition, ONC began the Data Segmentation for  Privacy Initiative to develop and pilot test standards for managing patient  consents and data segmentation. As part of this initiative, ONC released  an implementation guide for consent management and data segmentation  in the summer of 2012, and the agency is currently pilot testing this guide.  In addition, ONC’s state HIE organization program is currently receiving  reports from states on how they are implementing their state’s privacy  rules. Officials expect to receive the information from states by March  2014. ONC officials are hopeful that these efforts will help address  privacy concerns and, as a result, facilitate exchange efforts for providers.
Although ONC is working on privacy issues, some providers we spoke  with reported that lack of clarity in state privacy laws is one reason that  they have experienced difficulty exchanging health information with  providers in other states. They found it difficult to ensure they were  compliant with state laws when exchanging certain personal health  information with providers in another state. For example, some providers  in Minnesota and Massachusetts noted that some state laws have  stringent requirements related to sharing health information related to  mental health, or human immunodeficiency virus or other sexually  transmitted infections. In addition, some providers told us that different  providers in their state have different interpretations regarding how  frequently they must obtain consent from the patient, as required under  the state privacy rule, for the exchange of patients’ health information. For  example, some providers may interpret the state privacy rule to mean that  every time a patient’s health information is exchanged with another  provider they have to obtain consent. Other providers in the same state  may interpret the state privacy rule to mean that they have to obtain  consent only once.
In addition to the privacy challenges identified by providers, stakeholders  responding to HHS’s March 2013 RFI also identified privacy as a  challenge related to health information exchange, and noted that  additional training for providers on varying state privacy laws is needed to  address this challenge. Stakeholders also suggested that HHS could  focus more resources on consent policies and recommended that HHS  undertake additional work to facilitate (1) electronically obtaining patient  consent for disclosing health information, and (2) communicating that  consent along with the related health information.
Reported difficulty of accurately matching patients to their health  records. Some providers we interviewed reported that they do not have  an accurate and efficient way to match patients to their records when  exchanging health information. Multiple providers and stakeholders cited  situations in which several of their patients are listed with the same name  and birth year, and live in the same area. Two of these providers reported  that patients can be matched to the wrong set of records, and that  providers often need to manually match records, which is time- consuming. Some stakeholders also noted similar problems, including  safety concerns from incorrect patient matching.
HHS programs or initiatives to address patient matching issues related to  health information exchange include both a patient matching project and  efforts by two federal advisory committees. According to ONC officials,  planning for the Patient Matching Initiative was begun by the State Health  Information Exchange Cooperative Agreement Program in July 2013, and  the project launched publicly in September 2013. The goals of the  initiative are to (1) improve patient matching based on an assessment of  current approaches used by selected stakeholders, (2) identify key  attributes and algorithms for matching patients to their records, and   (3) define processes or best practices to support the identified key  attributes. The first phase of the initiative was completed in February  2014 with the release of a report containing patient matching  recommendations for possible inclusion in Stage 3 of the EHR programs   The two  and the 2015 edition of the standards and certification criteria.federal advisory committees established under HITECH, the HIT Policy  Committee and the HIT Standards Committee, made recommendations to  HHS in 2011 that relate to patient matching.recommended standardized formats for demographic data fields,  internally evaluating matching accuracy, accountability, developing,  promoting and disseminating best practices, and supporting the role of  the patient. The HIT Standards Committee made four recommendations  on patient matching covering patient attributes that could be used, data  quality issues, formats for data elements, and the data that could be  returned from a match request. According to ONC officials, as of July  2013 ONC had efforts under way to respond to these recommendations,  under the Patient Matching Initiative, in coordination with the committees.  For example, to address one recommendation related to developing,  promoting, and disseminating best practices, ONC officials said that they  plan to determine which approaches to patient matching work best and  develop guidance to help organizations implement such steps.
Although HHS has ongoing efforts to address the patient matching  challenge, several providers and stakeholders commented that more  work needs to be done on this issue. Some providers we interviewed use  different methodologies, such as algorithms that make use of multiple  patient attributes for identifying patients. However, providers told us that  they still have challenges matching patients to their records. Several  providers and stakeholders have stated that there should be a national  patient identifier for matching patients to their records.stakeholders who responded to HHS’s March 2013 RFI stated that HHS  has an opportunity to reduce the potential risks of engaging in exchange  by focusing more resources on patient matching.
Some  Reported challenges with cost of exchanging health information.  Providers we interviewed reported challenges covering costs associated  with health information exchange, including upfront costs associated with  purchasing and implementing EHR systems, fees for participation in state  or local HIE organizations, and per-transaction fees for exchanging health  information charged by some vendors or HIE organizations. Several  providers said that they must invest in additional capabilities such as  establishing interfaces for exchange with laboratories or other entities  such as HIE organizations. For example, many providers told us that the  cost of developing, implementing, and maintaining interfaces with others  to exchange health information is a significant barrier. One provider and  several officials estimated various amounts between $50,000 and  $80,000 that providers spend to establish data exchange interfaces.  Other stakeholders we interviewed or who responded to HHS’s March  2013 RFI also identified costs associated with participation in HIE  organizations and maintaining EHR systems as a challenge for providers.
To address costs of exchanging health information, ONC’s State Health  Information Exchange Cooperative Agreement Program has provided  funding to HIE organizations. Agency officials stated that by funding HIE  organizations, a relatively low cost option can be made available for  providers to use to exchange health information. However, ONC officials  said that this program is scheduled to end in March 2014. In addition,  several providers we interviewed told us that for them the benefits to them  of joining an HIE organization often do not exceed the costs, in some  cases because few providers have joined their state or regional HIE  organizations, resulting in limited opportunities to exchange health  information. Some providers told us they do not participate in HIE  organizations because they exchange information in other ways that they  believe are more efficient, such as exchanging directly with other  providers that use the same EHR system from the same vendor. One  study noted that most health care providers, including over 65 percent of  hospitals and 90 percent of physician practices, were not participating in  HIE organizations.
HHS payments to providers under the EHR programs can help support  the cost of exchange, but providers can participate in the programs  without routinely exchanging information electronically that could lead to  improved care. While some of the meaningful use requirements for   Stage 1 and Stage 2 help to facilitate the exchange of health information,  they require exchange only under certain circumstances. (See app. II for  more information.) For example, one part of the requirement to provide a  summary care document for each transition of care or referral in Stage 2  compels providers to complete either (1) one successful electronic  exchange of a summary of care record with a recipient using technology  designed by an EHR developer other than the sender’s, or (2) one  successful test with CMS’s test EHR during the reporting period. stakeholder we spoke with explained that for this part of the requirement  some providers just complete one successful test with CMS’s test EHR  and do not routinely demonstrate exchanging health information  electronically with other EHR systems. HHS officials stated that Stage 2 is  an incremental step toward advancing exchange, and that providers  generally do not yet have the technology to enable greater exchange.
The requirement to provide a summary of care document for each transition of care or  referral in Stage 2 also requires eligible professionals and hospitals to provide summary of  care documents for more than 10 percent of transitions of care and referrals either   (1) electronically transmitted using certified EHR technology or (2) through an exchange  with an organization that is a Nationwide Health Information Network Exchange participant  or in a way that is consistent with the Nationwide Health Information Network. The  Nationwide Health Information Network was a program funded by ONC that transitioned to  the eHealth Exchange, a group of federal agencies and nonfederal organizations whose  mission, among other things, is to improve public health reporting through secure, trusted,  and interoperable health information exchange.
CMS and ONC have identified a minimum set of technical capabilities that are required for  an EHR to be considered a test EHR. Eligible professionals and hospitals that select to  attest to this requirement will be randomly matched with a designated test EHR that is  designed by an EHR developer other than the sender’s.
section_title: HHS Developed an Electronic Health Information Exchange Strategy That Includes Principles to Address Key Challenges but Lacks Specific Prioritized Actions and Milestones
paragraphs: HHS, including CMS and ONC, developed and issued a strategy  document in August 2013 that describes how it expects to advance  electronic health information exchange, with principles to guide future  actions in three broad areas—accelerating health information exchange,  advancing standards and interoperability, and patient engagement.  Examples of principles in the strategy include (1) working with multiple  stakeholders to develop standards and facilitating the adoption and use of  standards among federal agencies; (2) supporting the privacy, security,  and integrity of patient health information across health information  exchange activities; (3) seeking to enable a patient’s health information to  be available wherever the patient accesses care, to support patient- centered care delivery; and (4) supporting exchange through state-led  efforts to reduce costs to providers. (See app. III for a complete list of  principles.) According to the strategy, these principles have the potential  to address the key health information challenges identified by providers  and stakeholders we interviewed, which relate to standards, patients’  privacy, matching patients with data, and costs.
GAO-04-408T.
See Pub L. No. 103-62, 107 Stat. 285 (1993) (GPRA), as amended by Pub. L. No. 111- 352, 124 Stat. 3866 (2011) (GPRAMA). GPRA requires, among other things, that federal  agencies develop strategic plans that include agencywide goals and strategies for  achieving those goals. We have reported that these requirements also can serve as  leading practices for planning at lower levels within federal agencies, such as individual  programs or initiatives. programs and to determine whether adjustments need to be made in  order to maintain progress within given time frames. Below are  examples of how the lack of these elements affects the HHS strategy.
Specific Actions. While the strategy mentions that HHS seeks to  enable a patient’s health information to be available wherever the  patient accesses care, it does not indicate specific actions that HHS  will take to implement that principle or how those actions would  overcome exchange-related challenges. Including specific actions  could enhance the strategy’s usefulness for helping to make program  management decisions.
Prioritized Actions. While the HHS strategy states that HHS will  continue to evaluate short- and long-term steps to advance exchange,  it does not clearly delineate how future actions related to the  principles should be prioritized. Prioritizing actions can help HHS  ensure that the most appropriate activities are completed first, to more  efficiently achieve the goal of advancing exchange.
Milestones. The HHS strategy does not provide milestones with  specific time frames to help the agencies gauge their progress in  advancing exchange. Exchange-related milestones with specified time  frames could be particularly useful because they could provide a  framework for determining whether any actions HHS intends to take  could help lead to progress in addressing the challenges providers  face related to exchange. Milestones with time frames could also set  realistic expectations so stakeholders can anticipate when they can  expect to see actions to advance exchange.
CMS and ONC officials acknowledged the importance of providers being  able to exchange health information effectively by Stage 3 of the EHR  programs to allow for improved outcomes such as quality, efficiency, and  patient safety. Determining specific, prioritized actions and exchange- related milestones with specified time frames can help to ensure that the  agencies’ principles and future actions result in timely improvements in  addressing the key exchange-related challenges reported by providers  and stakeholders, which are particularly important because planning for  Stage 3 is expected to begin as soon as 2014. This information could also  help HHS prioritize its future actions based on whether health information  is being exchanged effectively among providers, in order to better achieve  the EHR programs’ ultimate goals of improving quality, efficiency, and  patient safety.
section_title: Conclusions
paragraphs: HHS and providers have made some progress toward addressing  challenges reported by providers and others related to the electronic  exchange of health information, but these challenges are complex and  difficult to address and are likely to continue to persist. Some of HHS’s  most important efforts, such as designing the 2014 edition of the  standards and certification criteria to include an increased exchange  capability in EHR systems, may lead to greater exchange over the next  year. In addition, exchange may increase as providers modify their  systems to meet more stringent exchange-related requirements in   Stage 2 of the EHR programs. However, a number of remaining  challenges make these outcomes uncertain.
HHS has both ongoing programs and future plans to address concerns  about exchange, but it is not always clear how HHS will effectively  prioritize and implement its potential responses to the challenges of  exchange. Specifically, the HHS strategy to advance electronic health  information exchange does not identify specific actions that CMS and  ONC expect will lead to increased exchange, prioritize these actions, or  include milestones for gauging progress over time. Guidance on planning  and implementing effective strategies highlights the importance of key  elements, such as specific, prioritized actions and milestones for gauging  progress. These elements could help the agencies make future  adjustments based on the effectiveness of their efforts. Exchange is  especially important because of its potential to help improve coordination  of care within the fragmented health care system. According to CMS and  ONC officials, ensuring progress in providers’ ability to electronically  exchange information is critical for the effective implementation of the  EHR programs. Without a sufficient focus on exchange—including  specific, prioritized actions with milestones and time frames—CMS and  ONC run the risk that the desired outcomes of the EHR programs of  improved quality, efficiency, and patient safety will be compromised.
section_title: Recommendations for Executive Action
paragraphs: To address challenges that affect the ability of providers to electronically  exchange health information, we recommend that the Secretary of Health  and Human Services direct CMS and ONC to take the following two  actions: develop and prioritize specific actions that HHS will take consistent  with the principles in HHS’s strategy to advance health information  exchange; and develop milestones with time frames for the actions to better gauge  progress toward advancing exchange, with appropriate adjustments  over time.
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 IV. HHS concurred  with our recommendations. For the first recommendation, HHS (including  CMS and ONC) stated that it has begun to develop and prioritize specific  action items, consistent with the principles in its strategy to advance  health information exchange, and that it has begun to take action on  some of the prioritized items. For the second recommendation, HHS  (including CMS and ONC) stated that it has begun developing milestones  with time frames for the actions to better gauge progress toward  advancing exchange. In general, HHS’s comments also reiterated that the  electronic exchange of health information is a key element of meaningful  use and ultimately will be critical for the success of health care delivery  system reforms under the Patient Protection and Affordable Care Act.  HHS also stated that it has begun to take definitive steps to accelerate  exchange through policy guidance, grant funding to states, and  development of standards and certification, such as collaborating with  private sector organizations that develop health IT standards to fill key  gaps in standards to better support information exchange during  transitions in care and when coordinating care across providers.  Additionally, HHS provided technical comments, which we incorporated  as appropriate.
We are sending copies of this report to the Secretary of Health and  Human Services, the Administrator of CMS, the National Coordinator for  Health Information Technology, and other interested parties. In addition,  the report will be available at no charge on GAO’s 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 V.
section_title: Appendix I: Information Reported by Providers on the Electronic Exchange of Health Information and Its Related Benefits
paragraphs: This appendix provides additional information reported from providers we  spoke with about health information exchange and its related benefits.  We conducted a total of 25 interviews with providers and stakeholders,  such as regional extension centers (REC) and health information  exchange organizations (HIE organization), in four states—Georgia,  Massachusetts, Minnesota, and North Carolina. We interviewed staff from  at least two hospitals or health systems and at least one physician office  or group practice in each state. We selected the four states because they  were mentioned during interviews with officials from HHS and relevant  stakeholders as having ongoing efforts related to health information  exchange. We asked interviewees about what types of patient health  information providers are currently able to electronically exchange, the  methods used to exchange such information, and the benefits providers  have realized or foresee from such exchange.
Providers we interviewed reported that the most critical types of health  information that they need to be able to electronically exchange include  patient allergy information, medication lists, and problem lists. However,  providers generally reported being able to electronically exchange only  specific types of health information at this time, including lab orders and  results, immunization and prescription information, and certain clinical  documents. For example,
Almost all the providers we interviewed reported some exchange of  lab information. In most cases, such exchanges involved both the  submission of lab orders and the receipt of lab results via interfaces  designed for exchange between providers and labs or through their  electronic health record (EHR) system. While these exchanges were  reported to generally occur between providers and laboratories  outside their organizations, two providers noted that such capabilities  were still limited to sharing lab information with others in the same  health system.
Some providers also reported electronically exchanging some  information with state public health departments, generally  immunization data and notification of certain infectious diseases. They  said that these electronic exchanges were generally limited to  submissions to the departments and did not include receipt of data  from these departments.
Several of the providers we interviewed said they engaged in e- prescribing activities, which in some instances included both the  submission of electronic prescriptions to pharmacies and the receipt  of medication information from pharmacies. However, some providers  noted that such exchanges could take place only if the pharmacy had  a compatible e-prescribing system that could electronically receive  prescription information from the provider’s EHR system. In the  absence of compatible systems, faxes were used.
Several providers we interviewed also noted that they could exchange  continuity of care documents (CCD) with other providers in their  organization, although the exchange of this type of information varied  among the providers we interviewed. Several providers said they  could exchange CCDs within their health system, whereas other  providers said they could exchange this information only with  providers using the same EHR vendor.
Providers in all four states and stakeholders that we interviewed reported  that, at this time, methods used to electronically exchange health  information are limited to use within health systems, use between certain  EHR systems, or use of the Direct Protocol. For example, In Georgia, REC officials and the four providers we spoke with told us  that electronic exchange is generally occurring only within health  systems and among those affiliated providers that work in the health  systems. Some providers noted that they could electronically  exchange lab orders and results outside their organizations, but one  provider noted that even this information was still exchanged  electronically only within its hospital.
Providers in Minnesota, Massachusetts, and North Carolina reported  that they used the same EHR system from the same vendor and were  able to electronically exchange all patient clinical information with any  other entity using that vendor via an interoperability feature.
According to these providers, this interoperability feature provides a  mechanism for them to electronically exchange all types of clinical  information about their patients.
A community-based hospital in Minnesota reported using a different  EHR system than was used by the other, larger health systems in the  community it shared information with. This provider reported relying  on the Direct Protocol to electronically exchange some limited health  information with other providers in the region. A provider in  Massachusetts noted that it was building web-based “view portals” to  allow other providers outside its health system to view health  information electronically in order to help coordinate patient care.
Providers that participated in an HIE organization reported being able to  electronically exchange health information with other providers. Others  have opted to electronically exchange information using their EHR  technology rather than an HIE organization, even if one was available.
In Massachusetts, some providers told us that they are able to directly  connect to the state’s HIE organization in order to electronically  exchange health information, such as CCDs. However, not all  providers in the state are electronically exchanging information at this  time. A Massachusetts law calls for the creation and maintenance of a  state HIE organization that allows providers in all health care settings  to exchange patient health information with other providers by the end  of 2016.
Some providers we spoke with in Minnesota said they had no plans to  join any of the HIE organizations available in the state at this time due  to the limited benefits they would realize from participating, and would  instead continue to rely on their EHR technology to electronically  exchange health information with other providers that use the same  vendor. Some providers noted that without a sufficient number of  other providers participating in an HIE organization, it would be of  limited value.
Several Georgia and North Carolina providers reported that the  availability of an HIE organization could help facilitate electronic  exchange among providers. Entities in both states are establishing  regional HIE organizations that will ultimately connect to one another  via a statewide HIE organization. Providers in both states said they  expected that the HIE organizations, once established, would facilitate  broader electronic exchange of health information throughout the  state.
Although providers we interviewed described certain circumstances when  they could electronically exchange health information, they indicated that  they would like to expand the electronic exchange of health information  and cited a variety of benefits related to such electronic exchange. For  example, some providers noted that electronic exchange can provide access to critical information needed when administering  medical care, thus improving care quality and reducing duplicative  testing;  improve access to information related to a patient’s health history,  including medication histories and previous diagnoses;  result in more timely access to information, which is particularly  helpful in emergency departments; and  reduce labor-intensive efforts to send and receive health information  in paper form, such as a printed document, or conduct public health  reporting activities.
section_title: Appendix II: Stage 1 and Stage 2 Meaningful Use Measures Related to Electronic Health Information Exchange
paragraphs: This appendix provides information on the Stage 1 and Stage 2  meaningful use measures related to electronic health information  exchange, according to officials from the Centers for Medicare &  Medicaid Services (CMS) and the Office of the National Coordinator for  Health Information Technology (ONC). According to these officials,   Stage 2, which began in 2014, provides additional requirements related to  the exchange of health information. For example, some meaningful use  measures related to health information exchange that providers could  select from a menu of optional measures in Stage 1 are mandatory for  Stage 2. In addition, some Stage 2 measures are new. For example, the  measure “provide structured electronic lab results to ambulatory  providers” is a new measure for hospitals in Stage 2. See table 1 for more  information.
section_title: Appendix III: CMS and ONC Principles to Facilitate Health Information Exchange
paragraphs: This appendix provides information on the principles that the Centers for  Medicare & Medicaid Services (CMS) and the Office of the National  Coordinator for Health Information Technology (ONC) plan to use to  guide their future actions to facilitate health information exchange. These  principles are outlined in a strategy that the agencies released in August  2013 to describe how they expect the principles to lead to future actions  that have the potential to address the key challenges providers and  stakeholders have identified relative to electronic health information  exchange in four areas—standards, patients’ privacy, matching patients  with data, and costs. The strategy includes principles under three broad  categories—accelerating health information exchange, advancing  standards and interoperability, and patient engagement. See table 2 for  more information.
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Will Simerl, Assistant Director;   La Sherri Bush; Thomas Murphy; Monica Perez-Nelson; Roseanne Price;  Andrea Richardson; Teresa Tucker; and Rebecca Rust Williamson made  key contributions to this report.