Health Information Technology: HHS Should Assess the Effectiveness of Its Efforts to Enhance Patient Access to and Use of Electronic Health Information
Published: 2017-03-15T00:00:00

Fast Facts:
The Department of Health and Human Services wants all Americans to be able to access their health records electronically. Health care providers that participated in HHS's Medicare Electronic Health Record Incentive Program offered nearly 9 out of 10 patients the ability to access their health information online.
We found that relatively few of these patients accessed their records online, and patients typically did so in response to a medical visit. We also found that HHS doesn't know how effective its efforts to increase online access have been. We recommended HHS develop performance measures to assess the effectiveness of these efforts.

Highlights:
section_title: Why GAO Did This Study
paragraphs: HHS's goal is that all Americans will be able to electronically access their longitudinal health information, that is, their health information over time. HHS's efforts to achieve this goal include the Medicare EHR Program and other efforts to encourage providers to make patient health information available and for patients to access such information.
GAO was asked to review the state of patients' electronic access to their health information. This report (1) describes the electronic access to health information available to patients, and patients' views of this access, (2) describes the extent to which patients electronically access their health information, and actions providers reported taking to encourage such access, and (3) evaluates HHS's efforts to advance patients' ability to electronically access their health information. GAO analyzed data from HHS and other sources; reviewed applicable strategic planning documents; surveyed a generalizable sample of providers that participated in the Medicare EHR program; and interviewed HHS officials and a nongeneralizable sample of patients, providers, and health information technology product developers.
section_title: What GAO Found
paragraphs: Since 2009, the Department of Health and Human Services (HHS) has invested over $35 billion in health information technology, including efforts to enhance patient access to and use of electronic health information. One of the largest programs is the Centers for Medicare & Medicaid Services' (CMS) Medicare Electronic Health Record Incentive Program (Medicare EHR Program), which, among other things, encourages providers to make electronic health information available to patients. Program data for 2015 show that health care providers that participated in the program (3,218 hospitals and 194,200 health care professionals such as physicians) offered most of their patients the ability to electronically access health information. Patients generally described this access as beneficial, but noted limitations such as the inability to aggregate their longitudinal health information from multiple sources into a single record.
Data from the 2015 Medicare EHR Program show that relatively few patients electronically access their health information when offered the ability to do so. Patients GAO interviewed described primarily accessing health information before or after a health care encounter, such as reviewing the results of a laboratory test or sharing information with another provider.
While HHS has multiple efforts to enhance patients' ability to access their electronic health information, it lacks information on the effectiveness of these efforts. The Office of the National Coordinator for Health Information Technology (ONC) within HHS collaborates with CMS to assess CMS's Medicare EHR Program as well as its own efforts to enhance patient access to and use of electronic health information. However, ONC has not developed outcome measures for these efforts consistent with leading principles for measuring performance. Without such measures, HHS lacks critical information necessary to determine whether each of its efforts are contributing to the department's overall goals, or if these efforts need to be modified in any way.
section_title: What GAO Recommends
paragraphs: GAO recommends that HHS 1) develop performance measures to assess outcomes of key efforts related to patients' electronic access to longitudinal health information, and 2) use the information from these measures to help achieve program goals. HHS concurred with the recommendations.

section_title: Letter
paragraphs: Since the enactment of the Health Information Technology for Economic  and Clinical Health (HITECH) Act in 2009, the federal government has  invested over $35 billion to accelerate the development and adoption of  health information technology (IT). These efforts are aimed at  encouraging investment in and the use of electronic health records (EHR)  and related technologies that, among other things, enable patients to  access their health information when they need it in a useful electronic  format. This health information can include, for example, summaries of  vital signs, such as blood pressure; laboratory test and other screening  results; and information on present and past prescriptions. One of the  goals of the Office of the National Coordinator for Health Information  Technology (ONC), an office within the Department of Health and Human  Services (HHS), is for patients to have the ability to electronically access  and aggregate their longitudinal  health information in order to provide  comprehensive information on their health over time. According to ONC,  when patients have such access to their health information, they are  better able to monitor chronic conditions, ensure their health information  is accurate, and share their health information with providers when  needed.
In a 2016 report to Congress, ONC noted that patients’ ability to  electronically access their health information has increased over time,  though there are limitations to this access. ONC reports that in 2012,  only one-quarter of hospitals provided patients with the ability to  electronically view their information; in 2015, 95 percent of hospitals  offered this ability. However, ONC has reported that electronic health  information is often spread across multiple providers using disparate  systems that are not interoperable. ONC has reported that this dispersal  makes it cumbersome for individuals to aggregate their electronic health  information from different providers into a single longitudinal health  record.
You asked that we review the status of health IT interoperability  from the  perspective of the patient, specifically focusing on patients’ ability to  access, control, and contribute to their electronic health information. In  this report, we  (1) describe the extent and type of electronic access to health information  currently available to patients, and patients’ views about this access;  (2) describe the extent to which patients electronically access their health  information, and actions providers reported taking to encourage such  access; and  (3) evaluate HHS’s efforts to advance patients’ ability to electronically  access their health information.
To address our first two objectives, we undertook several steps. We  conducted a literature search to identify articles published between 2014  and 2015 that describe how patients electronically access their health  information. We identified and reviewed 51 such articles. In addition, we  analyzed data provided by the Centers for Medicare & Medicaid Services  (CMS) for the Medicare EHR Incentive Program (Medicare EHR  Program) for program year 2015 showing the extent to which providers— hospitals and health care professionals (e.g., physicians)—participating in  this program reported offering patients in their hospital or practice the  ability to electronically access health information and the extent to which  patients used these features. We also supplemented these data with  other types of data from CMS, ONC, the Health Resources and Services  Administration (HRSA), and the U.S. Census Bureau to identify the  characteristics of these providers and patients. We assessed the  reliability of these data by (1) performing electronic testing of required  data elements, (2) reviewing existing information about the data and the  system that produced them, and (3) consulting agency officials who are  knowledgeable about the data. We determined that these data were  sufficiently reliable for the purposes of our reporting objectives. (See  Appendix I for more details of our analysis.) We also interviewed relevant  experts to learn about patients’ ability to electronically access health  information. Specifically, we interviewed knowledgeable individuals in the  area of health IT and patient electronic access from Mathematica Policy  Research, the American Health Information Management Association,  Healthwise, the National Association for Trusted Exchange, and the Open  Notes Foundation, as well as individuals conducting advocacy work in this  area. We selected these organizations and individuals based on mentions  in previous interviews and references in literature.
As part of our work for our first two objectives, we also obtained  information on the perspectives of patients, providers, and health IT  developers on patient electronic access to health information, as follows.
To obtain patients’ perspectives, we interviewed a nongeneralizable  sample of 33 patients to learn about their experiences electronically  accessing their health information. Patients Like Me, a patient  advocacy organization, agreed to let us post a request on its website  seeking to interview patients. The request directed patients to contact  us directly if they were interested in talking about their experiences  electronically accessing their health information. We were able to  successfully schedule and complete interviews with 33 of these  patients. During these interviews, we asked the patients about  instances when they electronically accessed their health information,  challenges they encountered when accessing or attempting to access  such information, benefits they experienced as a result of such  access, and improvements they would like to see.
To obtain providers’ perspectives, we conducted a nationally  representative survey of 1,867 providers who participated in the  Medicare EHR Program for the 2014 program year. We received valid  survey responses from 175 hospitals and 253 health care  professionals. The weighted response rate, which accounts for the  differential sampling fractions within strata, is 21 percent for the full  sample, 28 percent for eligible hospitals, and 20 percent for eligible  professionals. In the survey, we asked providers about the methods  they use to give their patients electronic access to their health  information, the perceived benefits of giving patients such access, and  the steps providers have taken to encourage electronic access by  their patients, among other things. (See Appendix I for a more  detailed description of our provider survey.) We also interviewed 6  providers who volunteered to speak with us after responding to our  survey to learn about their perspectives on patient access to  electronic health information. The views of these 6 providers are not  generalizable to all providers.
To obtain health IT developers’ perspectives, we interviewed a  nongeneralizable sample of individuals from 16 companies in the field  of health IT. We identified these companies through interviews and  internet searches as companies that are developing or have  developed products that facilitate patients’ electronic access to health  information. Specifically, we interviewed 10 health IT developers who  are working to develop or who have developed applications intended  to enable consumers of their products to access their electronic health  information and aggregate it into a single location; representatives  from 2 EHR vendors that offer portals that providers can purchase so  that their patients can electronically access their health information;  representatives from 2 companies that are working on health IT  projects related to consumer access to health information; and  representatives from 2 other companies that promote the  development of health IT platforms that enable consumers to  electronically access their health information.
To evaluate HHS’s efforts to advance patients’ ability to electronically  access their health information, we reviewed relevant documents, such as  strategic plans and agency budget justifications, for both ONC and CMS  for fiscal years 2015 and 2016, the most recent years available. We  compared the information and documentation to relevant criteria from  GAO’s body of work on effectively managing performance under the  Government Performance and Results Act of 1993. We also interviewed  officials from CMS and ONC about each agency’s efforts to further the  ability of patients to electronically access their health information and the  extent to which their agencies are evaluating these efforts.
We conducted this performance audit from September 2015 to March  2017 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Medicare and Medicaid EHR Incentive Programs and Patient Electronic Access
paragraphs: The largest federal investments in health IT and patient electronic access  to health information are the Medicare and Medicaid EHR Incentive  Programs. These programs provide incentives to hospitals and health  care professionals that are able to demonstrate meaningful use of a  certified EHR system. Providers must attest that they have met certain  measures in order to receive payment, with the required functions  increasing in complexity as providers move through the stages of the program. Among the measures in the current programs are two that are  specifically designed to capture the extent to which patients are able to  electronically access their health information. Unless providers claimed  an exclusion from reporting these measures, providers were required to  successfully complete them in order to receive incentive payments for  program year 2015. The measures are as follows:  (1) Ability  to electronically access health information. More than 50  percent of a providers’ patients must be provided timely access to  view online, download, and transmit to a third party their health  information, and  (2) Actual electronic access. At least one of a provider’s patients must  electronically view, download, or transmit to a third party their  information during the 90-day reporting period.
Providers participating in these EHR Programs must use certified EHR  technology, which is technology that has been determined to conform to  standards and certification criteria developed by ONC. These criteria do  not specify a particular technical method for providing patients with  access to their health information, but do specify parameters for  accessing certain types of health information. According to ONC, many  providers use some type of patient portal to provide access to these types  of health information. A patient portal is a secure online website that gives  patients 24-hour access to their personal health information and medical  records from anywhere with an Internet connection. Patient portals are  purchased by a provider and generally only include health information  generated and made available by that individual provider.
section_title: Federal Health Information Technology Strategic Plans
paragraphs: ONC released the most recent strategic plan for health IT, developed with  input from federal and nonfederal stakeholders, in September 2015. This  plan guides the actions of multiple federal agencies with regard to health  IT. The plan outlines four primary goals, each with its own objectives for  using health IT, to improve the health and well-being of individuals and  communities. Two of these goals are to transform health care delivery  and community health and advance person-centered and self-managed  care. In addition to this strategic plan, in 2015 ONC developed, with  input from federal and nonfederal stakeholders, a Shared Nationwide  Interoperability  Roadmap (which we refer to in this report as the  Roadmap). The Roadmap proposes specific actions to advance the  nation towards an interoperable health IT system that collectively  improves health. The Roadmap includes the goals that patients can  access their longitudinal  electronic health information, contribute to this  information, send and receive that information through a variety of  technologies, and use that information to manage their health and  participate in shared decision making with their health care providers.  These Roadmap goals support the HHS strategic plan goals of advancing  care and transforming health care delivery and community health.
section_title: Performance Management and Assessment
paragraphs: Performance measures assess performance via ongoing monitoring and  reporting of program accomplishments, which include progress toward  pre-established goals. Our previous work has found that performance  measures can serve as an early warning system to management and as  a vehicle for improving accountability to the public. We have also  published guidance on assessing performance which states that it is  important for performance measures to be tied to program goals and for  agencies to ensure that their activities support their organizational  missions and move them closer to accomplishing their strategic goals.  In addition, our guidance to federal agencies on designing evaluations  suggests that performance measures should include both process and  outcome measures. (See table 1.) Outcome measures are particularly  useful in assessing the status of program operations, identifying  areas  that need improvement, and ensuring accountability for end results.  Furthermore, our guidance on assessing performance notes that leading  organizations should not only establish performance measures but also  use information from these performance measures to continuously  improve processes, identify program priorities, and set improvement  goals.
section_title: Most Patients of Providers Participating in the 2015 Medicare EHR Program Were Offered Electronic Access to Their Health Information and Noted Benefits and Limitations of Such Access
paragraphs: Data from CMS show that most patients who received their health care  from providers participating in the Medicare EHR Program had the ability  to electronically access their health information. Information from our  survey of providers and interviews with patients and providers show that  this access is typically offered through patient portals and the type of  information offered varies. In interviews, patients described the benefits  and limitations of accessing their health information electronically.
subsections: section_title: Almost 90 Percent of Patients Receiving Care from Providers Participating in the 2015 EHR Program Had Electronic Access to Their Health Information
paragraphs: CMS data show that providers who participated in the 2015 Medicare  EHR Program reported offering most of their patients the ability to  electronically access their health information. In 2015, all participating  hospitals and nearly all participating health care professionals reported  offering electronic access to health information to 88 and 87 percent of  their patients respectively, on average. This means that the providers  gave the patients they saw or discharged all of the information necessary  to electronically view, download, and transmit the patients’ health  information, such as a website address, a username and password, and  instructions for logging onto the website.
Our survey of providers who participated in the 2014 Medicare EHR  Program and interviews with providers further illustrate the extent to  which providers offered their patients electronic access to their health  information. Our survey found that nearly all providers routinely provided  new patients with access to this information (92 percent of health care  professionals and 91 percent of hospitals). Providers we interviewed also  described circumstances in which a patient may not have been offered  access. These circumstances included instances such as in emergency  care, when offering electronic access may not be appropriate at the point  of care, or for behavioral health data, when it might not be in the best  interest of the patient to access the information.
ONC has published information on the extent to which non-federal acute- care hospitals and office-based physicians provide their patients with  access to their health information. ONC reported that in 2015, almost all  hospitals (95 percent) offered patients the ability to electronically view  their health information, and about 7 out of 10 (69 percent) hospitals  provided their patients with the ability to view, download, and transmit  their health information electronically. In addition, ONC recently reported  that among office-based physicians, 63 percent provided patients with the  ability to electronically view their health information. ONC reported in  another data brief that in 2014, nearly 4 in 10 Americans were offered  electronic access to their medical records.
section_title: Providers Who Participated in the 2014 EHR Program Generally Used Patient Portals to Make Various Types of Health Information Available to Patients
paragraphs: Our survey of providers who participated in the 2014 Medicare EHR  Program found that most providers offered electronic access to patients  through a patient portal, and our interviews suggest that patients often  received access to a different portal for each provider. A patient portal is  a secure website that allows patients to access information contained in  their provider’s EHR system and is managed by the provider. EHR  vendors and providers we interviewed noted that patients generally have  to manage separate login information for each provider-specific portal.  Many patients we interviewed confirmed this; for example, a number of  patients we interviewed said that they had access to more than one  portal, each of which contained their health information from a different  care setting (e.g., hospital stays, general practitioner, and different  specialists).
The types of health information that providers made available to patients  varied, but our survey of providers indicated that most routinely offer  access to most types of patient information. The Medicare EHR Program  requires that participants make certain types of information available,  such as laboratory test results and current medications. According to  our survey, an estimated 94 percent of hospitals and 77 percent of health  care professionals routinely offered access to laboratory test results,  which are required by the program. (See table 2.) Our survey also  showed that fewer providers routinely offered access to certain  information that is not required by the program and that they find less  helpful for their patients to view. For example, 46 percent of hospitals and  54 percent of health care professionals reported routinely offering access  to clinician notes, which are not required by the program. Additionally,  our  survey showed that fewer providers find it helpful for patients to view  clinician notes and radiological images than for patients to view  information such as laboratory results and current medications.  Representatives from two hospitals we interviewed explained that their  hospitals relied on a committee to decide what information to make  available to patients through the portal and how soon after it is available  to the provider to make it available to the patient. One EHR vendor we  spoke with noted that the vendor automatically makes almost all  information, including clinician notes, available to patients through the  vendor’s patient portal by default, though many vendors allow providers to  limit the types of information they routinely make available to patients.
Patients we interviewed said that the type of information made available  in their portals was incomplete and inconsistent across providers. Though  many patients talked about accessing their lab results through their portal,  multiple patients said that their results were not always available for them  to view. For example, one patient said that sometimes her lab results are  posted, and other times they are never made available to her, and she  does not have a sense of when the results will be made available. Three  patients expressed frustration that their vital signs information such as  weight and blood pressure was not available through their portals,  particularly since they knew that their providers collected this information  during visits. Another patient said that she has observed a lot of variability  in what information providers make available through their portals, with  some doctors providing access to detailed information such as clinical  notes and lab results, and others only making basic information available,  such as appointment reminders and vital signs information collected  during visits.
section_title: Patients Described Numerous Benefits and Some Limitations with Their Electronic Access to Health Information
paragraphs: During our interviews with 33 patients who have accessed their health  information electronically, patients described numerous benefits from the  ability to electronically access their health information. These benefits  included the ability to communicate better with their health care providers,  track health information over time, and share information with other  providers. Multiple patients described circumstances in which they used  information in their portal to improve their interactions with their provider  and adhere to provider recommendations. For example, one patient  described how he logged into the portal after a visit to review instructions  from his provider that he had forgotten. Patients also noted that  electronically accessing their health information made them feel  empowered or more proactive to manage their health, particularly over  time. For example, patients described using their electronic access to  view specific test results over time to see whether their condition was  changing, or to access diagnostic information that gave them the ability to  do more research on their medical condition. One patient described using  the information in her portal to notice a trend in her lab results and also  learn of a condition she had of which her provider failed to inform her.  Patients also described using their patient portals to share information  with other providers. Multiple  patients described printing out medical  information from their portals, such as lab results, and bringing that  information to appointments with other providers. Patients noted that  portals make sharing health information very convenient.
However, patients also described some limitations with their access,  many of which were related to the functionality of the portal. Patients we  interviewed stated that they were able to view their health information  electronically, but many patients said that it was not clear that this  information could be electronically downloaded or transmitted. Patients  also expressed frustration with the amount of time and effort it took to set  up electronic access through their providers, managing multiple  passwords for their many portals, and understanding each portal’s user  interface. Many patients said that the information itself was often incorrect  or not presented in helpful ways, and some patients noted that there was  no simple way to correct or denote incorrect information within the portal.  For example, one patient said that another person’s information was  included in her record, and it took multiple requests to her provider to  remove this information from her record. Another patient was frustrated  that information about his weight that was captured in his yearly physical  was not available in the portal in a way that would allow him to track his  weight over time.
Multiple  patients said that an overall limitation is that they could not  aggregate all of their health information into a single longitudinal health  record. While there are health IT products available to help patients and  providers aggregate information, they are not in high demand. For  example patient-purchased personal health records (PHR) can enable patients  to aggregate electronic information from disparate sources into a  single record. Health IT developers said that there are PHR products  available for patients who attempt to generate such a record, but our  survey and patient interviews indicate that these products are not  widely used. Health IT developers noted that these products have  limited functionality because they or the users (e.g., patients) cannot  access information stored in EHR systems, and one developer noted  that a lack of standardization limits the ability to present information in  a meaningful way. Patients we interviewed generally stated that they  were not using these products, and health IT developers agreed that  consumer demand is low. Additionally,  relatively few hospitals and  health care professionals we surveyed reported having the capability  to submit information to PHR products.
Provider-purchased products can also help patients and providers  aggregate longitudinal health information, according to health IT  product developers and EHR vendors we interviewed. For example,  one health IT developer explained that providers can currently  purchase their product to display information from multiple EHR  systems in a single portal; this product would need to be purchased  separately from the EHR system and would require additional  configuration. However, according to our survey, we estimate that  most providers offer patient portals that are packaged with their EHR  system. One EHR vendor representative said that the company was  currently in the process of developing a product that will enable  patients to access information from multiple providers using their EHR  system. However, that product has not been released for provider and  patient use.
section_title: Few Patients of Providers Participating in the Medicare EHR Program Electronically Accessed Their Health Information, and Providers Reported Taking Steps to Encourage Access
subsections: section_title: Less than One-third of Patients Electronically Accessed Their Health Information, and Patients Reported Such Access Generally Occurs Before or After Seeing a Provider
paragraphs: Providers participating in the Medicare EHR Program in 2015 reported  that relatively few patients electronically accessed their health information  when it was made available to them. In other words, few of these  patients logged into a patient portal and viewed, downloaded, or  transmitted their health information. Our analysis of 2015 Medicare EHR  Program data collected by CMS showed that among participating  hospitals, 15 percent of their patients electronically accessed their  available health information; among physicians and other health care  professionals, this percentage was twice as much, with about a third (30  percent) of their patients accessing their available health information.  (See fig. 1.)
Examining access rates by provider characteristics, our analysis shows  that some types of non-hospital based providers reported relatively low  percentages of patients accessing their health information electronically in  2015. Analyzing 2015 Medicare EHR Program data supplemented with  other HHS data, we found that among non-hospital based providers  participating in the 2015 program: health care professionals located in areas with a higher (i.e., above  the national median) percentage of residents in poverty and located in  rural areas reported lower levels of electronic access to health  information, compared with professionals in lower-poverty areas and  professionals located in urban areas; health care professionals with 50 or fewer group practice members  reported notably lower levels of electronic access to health  information compared with professionals with larger numbers of group  practice members; and health care professionals other than general or specialty  practitioners—including chiropractors, dentists, and podiatrists— reported notably lower levels of electronic access to health  information compared with professionals in general practice or  specialty practice. (See fig. 2.)
Examining access rates by age, our analysis of data from the 2015  Medicare EHR Program and data from HRSA’s Area Health Resources  File indicates that the level of electronic access to health information  reported by both hospitals and health care professionals was lower  among those located in areas with a higher percentage of the population  over age 65. (See fig. 3.)
The findings from our analysis of access rates by patient age are  consistent with other evidence suggesting that older patients may be less  likely to access their health information electronically compared with  younger patients. Providers we interviewed and who responded to our  survey, as well as health IT developers we interviewed, said that a  patient’s age affected the extent to which she electronically accesses her  health information. Multiple providers who responded to our survey and  that we interviewed conveyed that, in their experience, older patients are  less likely to electronically access their information. Providers and health  IT developers noted that younger patients and those with chronic  conditions are most likely to want electronic access to their health  information.
Some providers we surveyed and interviewed attributed the lack of  interest in accessing health information electronically among older  patients to a decreased likelihood of having access to a computer or web- enabled device. One provider stated that his hospital serves a large  elderly population and that this was the biggest challenge to meeting the  requirement under the 2014 Medicare EHR Program that over 5 percent  of patients access their health information electronically. A recent data  analysis by ONC found no differences in rates of access to or the viewing  of online medical records by age, but the analysis did find that individuals  between the ages of 50 and 59 had significantly higher rates of  electronically communicating with health care providers, looking up test  results online, and using smartphone health applications compared with  individuals 70 years or older. More generally, a 2013 survey conducted  by the Pew Research Center found that adults age 65 or older were most  likely to say that they never go online.
Age is not the only determinant as to whether patients electronically  access their health information. According to studies we reviewed,  patients may not access their health information frequently because they  do not have a reason to do so. In 2015, ONC reported that for 2013 and  2014, about three-quarters of surveyed individuals who reported that they  did not access their medical records online indicated that they did not do  so because they did not have a need to use the information. Similarly,  another study found that most patients who report rarely or never  accessing electronic health information say that they do not have a need  to do so.
According to patients we interviewed, patients who electronically access  their health information typically do so before or after a health care  encounter. For example, patients we interviewed said that they accessed  information in their portal to review information before or after an  encounter with a provider—for example, to review lab test results,  communicate with their providers about a recent appointment, or share  information between providers during visits. About half of the patients we  interviewed also described using portals offered by their providers to  access “convenience features” related to receiving health care, such as  features used to see appointment reminders, request medication refills,  message their provider, or schedule an appointment. Similarly, one of the  studies we reviewed found that consumers expressed preferences to use  online access to their health information primarily for needs that occur  before or after a health care encounter (e.g., to view recently completed  lab work or notes from a recent physician visit) or because they are  accessing convenience features offered in their provider’s portal, such as  online appointment scheduling or to request medication refills.
section_title: Providers Reported Taking a Variety of Actions to Encourage Patient Electronic Access
paragraphs: In our survey of 2014 Medicare EHR Program participants, providers  reported using a variety of outreach strategies and other efforts to  encourage their patients to access the health information made available  to them. These methods include promoting the use of patient portals and  providing prizes and other incentives to access the portals. (See table 3.)
Providers we interviewed similarly reported undertaking a variety of  efforts to encourage patients to electronically access their health  information. For example, a hospital representative stated that to increase  patient access, staff members tell patients about the portal and take steps  to register patients for the portal at every interaction. Another hospital  representative explained that hospital staff individually  assist patients and  even help patients obtain a private e-mail address to register for the  portal, if necessary. Yet another hospital representative said that the  hospital staff wore buttons instructing patients to ask staff about the  portal, and the hospital also installed billboards to remind patients to ask  staff about the portal. Despite these efforts, this hospital representative  said that they struggled to meet the patient electronic access  requirements under the Medicare EHR program.
Our interviews with the 33 patients and analysis of Medicare EHR  program data and our survey data indicate that the type of portal that  providers use may influence the extent to which patients access their  available health information. In particular, patients we interviewed noted  that they sometimes experienced technical difficulties when attempting to  access information through the portal or were confused by the portal’s  user interfaces. For example, patients noted that they were sometimes  unable to access information in their portals due to the sites being down  for maintenance or that their portals were not optimized for viewing on a  mobile device, which limited their ability to use the portal. Several patients  also expressed frustration with the user interface of the portal offered by  their providers, noting that it was difficult to navigate and find the  information they wanted. About two-thirds of the providers we surveyed  reported taking steps to improve their patient portal’s usability or design.  Our provider survey data indicate that most providers offer patient portals  that are packaged with their EHR system and therefore provided by the  same vendor. One vendor we interviewed noted that it allows for some  customization for each customer. We viewed demonstrations of three  EHR systems’ patient portals, and observed that the portal design does  vary by vendor. For example, the portals we viewed had differences in  their interfaces, including where to access health information and how  tabs were labeled. Our analysis of Medicare EHR Program data from  ONC and CMS confirms that the type of portal itself may affect the extent  to which patients access their available health information; the average  percentage of patients that accessed their available health information  varied depending on the provider’s reported EHR vendor. (See figs. 4   and 5.)
section_title: HHS Has Taken Steps to Increase Patients’ Electronic Access to Health Information but Lacks Outcome Measures to Determine the Effectiveness of These Efforts
subsections: section_title: HHS Programs and Other Efforts Aim to Further Patients’ Ability to Access Health Information Electronically, Including Longitudinal Health Information
paragraphs: HHS officials said that two agencies, CMS and ONC, have programs or  other efforts aimed at increasing the ability of patients to electronically  access their health information, including the ability to access longitudinal  health information and aggregate it in a single location. In the case of  CMS, agency officials told us that the Medicare and Medicaid EHR  Programs have made a significant contribution towards achieving these  goals. The two programs require participating hospitals and health care  professionals to provide electronic access to health information to a  specified portion of patients. According to CMS officials, the programs  support HHS’s strategic goals to improve health care through the  meaningful use of health information technology.
In the case of ONC, agency officials identified multiple efforts they are  undertaking to increase patients’ ability to electronically access their  health information, including longitudinal health information. Some  examples of these efforts include the following:
Patient Engagement Playbook. The playbook is a tool developed by  ONC to assist providers in engaging patients with health IT by, for  example, using patient portals to engage patients in their health and  care.
Blue Button Initiative. This initiative includes three distinct efforts – a  connector, a voluntary pledge program, and a research project. The  connector is a website that helps patients locate their health  information online and assists in the development of apps and tools to  help consumers understand their health information. The voluntary  pledge encourages public and private organizations—such as  providers, hospitals, technology companies, and non-profit  organizations—to commit to making health information available to  patients electronically and to encourage patient access. The research  effort is designed to understand the unmet needs and challenges  facing stakeholders.
Health IT Certification Standards and Certification Criteria. These  standards and criteria identify certain vocabularies and structured  formats that must be included in certified EHR systems and other  EHR technology that providers are required to use in order to  participate in the EHR programs.
Consumer Health Data Aggregator Challenge. By awarding private  sector innovation, this challenge aims to spur the development of  third-party consumer-facing applications that use open, standardized  application programming interfaces to help consumers aggregate their  data in one place.  (See Appendix II  for a list of ONC’s programs and efforts most directly  related to increasing patients’ ability to electronically access their health  information.)
Both CMS and ONC officials told us that their efforts aim to increase the  extent to which patients can electronically access their health information.  Officials said that their efforts are guided by goals such as the Roadmap’s  long-term milestone of enabling patients to access longitudinal health  information, contribute to their electronic health information (e.g., send  data from wearable devices to their electronic health record), and direct  their health information into any location of their choice (e.g., to a PHR  application purchased by the patient that aggregates all their health  information in a single location). According to ONC officials, the agency’s  efforts all support HHS’s Federal Health IT Strategic Plan as well as  ONC’s Roadmap, which establishes several milestones for the agency’s  ongoing efforts to increase patients’ ability to access their health  information electronically. These milestones are the following:  1)  a majority of individuals are able to securely access their electronic  health information and direct it to the destination of their choice (to be  achieved between 2015 and 2017);  2)  individuals regularly access and contribute to their longitudinal  electronic health information via health IT, send and receive that  information through a variety of emerging technologies, and use that  information to manage their health and participate in shared decision- making with their care, support, and service teams (to be achieved  between 2018 and 2020); and  3)  individuals are able to seamlessly integrate and compile longitudinal  electronic health information across online tools, mobile platforms,  and devices to participate in shared decision-making with their care,  support, and service teams (to be achieved between 2021 and 2024).
section_title: HHS Cannot Determine Whether Its Agencies’ Efforts Are Helping Increase Patients’ Electronic Access to Health Information
paragraphs: HHS does not have information on the effectiveness of CMS’s and ONC’s  efforts to increase the ability of patients to access their health information  electronically. Although ONC measures some progress related to these  efforts and the Medicare EHR Program, ONC does not directly measure  the impact of these efforts on increasing patients’ electronic access to  health information. In the case of CMS, officials told us that while they  track the number of providers that participate in the Medicare EHR  Program, the agency does not directly measure the extent to which the  program specifically affects patients’ ability to access their health  information electronically. However, HHS officials stated that they do  monitor the program by seeking public comments during the rulemaking  process and by publicly reporting statistics. Officials told us that ONC  collaborates with CMS to monitor and review the EHR Programs and has  used the results of these analyses to modify the programs over time.  ONC officials told us there is a data use agreement in place that allows  ONC to analyze Medicare EHR Program data. Additionally,  ONC  commissions evaluations of programs initiated under the HITECH Act,  including the Medicare EHR Program. While ONC’s data analyses and  commissioned evaluation provide information concerning patient access  to electronic health information and patient engagement, these efforts do  not measure the impact of the Medicare EHR Program on patients’ ability  to access their health information electronically.
In the case of ONC, ONC measures a range of outcomes associated with  its multiple efforts, but the office does not measure the extent to which its  individual efforts are having an effect on patients’ ability to access their  health information electronically—by determining, for example, if  providers that participate in these initiatives have higher rates of patient  access. ONC officials stated that they use metrics as a means of  assessing whether the technologies and resources made available  through ONC’s efforts are being utilized. For example, ONC officials told  us they count the number of website visits to the Patient Engagement  Playbook page, the number of providers and other stakeholders who  have pledged to make electronic health information available to their  patients through ONC’s Blue Button Initiative,  and the number of times  patients access educational videos about their right to access their health  information online.
According to officials, ONC also uses nationally  representative surveys of  hospitals, other providers, and patients that are fielded by various  organizations to measure the extent to which patients access their health  information electronically; however, the surveys cannot be used to  measure whether, or to what extent, ONC’s efforts most directly related to  patient access are achieving their intended effects. ONC’s survey data  identify, for example, how many patients reported being able to  electronically view, download, or transmit their health information as well  as if patients sent their health information to an app, mobile device, or  PHR. The survey of patients provides information on how patients are  accessing their health information and what they do with that information  once accessed. For example, the survey asks patients whether they have  attempted to electronically send their health information to another  electronic location such as a PHR application. Finally, the survey also  asks patients about the extent to which they experience any challenges  when electronically accessing their health information. ONC officials told  us that they plan to conduct a consumer survey with different questions in  2017; however, ONC has not finalized the questions for this survey.  According to ONC officials, these surveys help the agency understand  other factors, such as how broadband access and language influence  patient access and whether progress is being made generally towards the  Roadmap goal of increasing patients’ ability to access their health  information electronically.
HHS lacks information on the effectiveness of CMS’s and ONC’s efforts  because it has not developed outcome measures. For example, ONC  cannot determine if patient electronic access is higher for participants in  the Blue Button Initiative  compared with non-participants or if providers  who use the Patient Engagement Playbook achieve more patient  electronic access than non-users. In our prior work we have identified the  use of outcome measures as a leading principle for measuring  performance. Guidance for federal agencies based on these principles  calls for federal agencies to include outcome measures that address the  status of program operations, identify areas that need improvement,  ensure accountability for end results, and measure progress towards  agency strategic goals—in this case, HHS’s goals related to increasing  patients’ ability to access their health information electronically. Without  outcome-focused performance measures, HHS cannot determine  whether, or to what extent, each of its efforts are contributing to the  department’s overall goals, or if these efforts need to be modified in any  way.
section_title: Conclusions
paragraphs: Through CMS’s Medicare and Medicaid EHR Programs and ONC’s  multiple individual initiatives, HHS supports a wide range of efforts  intended to increase patients’ electronic access to their health  information. HHS’s investment in these efforts has been significant— since 2009 HHS has spent over $35 billion on the development and  adoption of health information technology. CMS’s and ONC’s efforts aim  to encourage the use of technologies that allow patients to electronically  access their longitudinal  health information, contribute to that information,  and direct it to any location of their choice. While HHS’s investment in  health information technology is significant, HHS lacks the ability to  determine whether, or to what extent, CMS’s and ONC’s efforts are  helping HHS achieve its goals. ONC is largely responsible for measuring  the nation’s progress towards increasing patients’ electronic access to  health information. However, ONC has not developed outcome measures  to directly measure the effectiveness of its individual  efforts, identify areas  that need improvement, and ensure accountability for achieving results.  Without such outcome-focused performance measures linked to relevant  agency goals, ONC—and by extension, HHS—cannot determine  whether, or to what extent, each of the programs and efforts is  contributing to overall goals, or if these efforts need to be modified in any  way.
section_title: Recommendations
paragraphs: To help ensure that its efforts to increase patients’ electronic access to  health information are successful, the Secretary of HHS should direct  ONC to take two actions.
First, develop performance measures to assess outcomes of key  efforts related to patients’ electronic access to longitudinal health  information. Such actions may include, for example, determining  whether the number of providers that participate in these initiatives  have higher rates of patient access to electronic health information.
Second, use the information these performance measures provide to  make program adjustments, as appropriate. Such actions may  include, for example, assessing the status of program operations or  identifying areas that need improvement in order to help achieve  program goals related to increasing patients’ ability to access their  health information electronically.
section_title: Agency Comments and our Evaluation
paragraphs: We provided a draft of this report to HHS for its review and comment.  HHS provided written comments, which are reprinted in appendix III.  HHS  also provided technical comments, which we incorporated as appropriate.  In its written comments, HHS concurred with both of our  recommendations.
With regard to our first recommendation, which calls for HHS to develop  performance measures to assess the outcomes of key efforts related to  patients’ electronic access to longitudinal health information, HHS noted  that ONC is committed to assessing the effects of health IT adoption and  use. HHS detailed efforts on the part of ONC and CMS to assess  progress in patients’ access to their electronic health information and said  that the department has used these assessments to modify its programs  for encouraging such use over time. HHS stated that there has been an  increase in patients’ ability to electronically access and use their health  information and noted that we said this in our report. With regard to our  statement that ONC is primarily responsible for assessing the effects of  the Medicare EHR Program, HHS raised concerns that this statement  was misleading because assessing the impact of the program is a  coordinated effort between ONC and CMS. In response, we changed our  description of the roles of ONC and CMS to reflect HHS’s comment.  While HHS has worked to assess the impact of its efforts, it agreed that  ONC has not developed a specific means for measuring outcomes  associated with ONC’s efforts aimed at furthering patients’ ability to  electronically access their health information. HHS also noted that ONC is  required by HITECH and the Medicare Access and Children’s Health  Insurance Program Reauthorization Act to develop performance  measures for the adoption of EHRs and related efforts to facilitate the  electronic use and exchange of health information. HHS stated that these  required performance measures involved nationwide surveys that go  beyond the scope of the Medicare EHR Program data discussed in this  report. Therefore, HHS stated that ONC would make every effort to  develop performance measures for patient education and outreach  initiatives but would have to balance these efforts with its efforts to  develop measures for the adoption of EHRs, interoperability, and patient  engagement nationwide.
In concurring with our second recommendation, that ONC use the  information the performance measures provide to make program  adjustments, HHS stated that it is committed to using performance  measures to guide program improvement.
We are sending copies of this report to the appropriate congressional  committees, the Secretary of Health and Human Services, and other  interested parties. In addition, the report is available at no charge on the  GAO website at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or at yocomc@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 IV.
section_title: Appendix I: Methodology for Medicare Electronic Health Record Incentive Program (Medicare EHR Program) Data Analysis and Provider Survey
paragraphs: This appendix provides additional details regarding our analysis of  Medicare EHR Program data and our nationally representative provider  survey. The data analysis and the provider survey were used, in part, to  describe the extent and type of electronic access to health information  currently available to patients, the extent to which patients electronically  access their health information, and the actions providers are taking to  encourage such access.
subsections: section_title: Methodology for Analysis of Medicare EHR Program Data
paragraphs: We analyzed data from the Centers for Medicare & Medicaid Services  (CMS) as supplemented with other government data to (1) determine the  number of providers—that is, hospitals and health care professionals  (e.g., physicians)—that participated in the 2015 Medicare EHR Program;  (2) determine the number of program participants who reported each of  two measures related to patient electronic access to health information;  (3) determine the extent to which program participants are offering  patients, and patients are using, the ability to electronically access their  health information; and (4) examine the characteristics of providers that  were associated with higher or lower percentages of patients who actually  accessed their available health information.
We assessed the reliability of these data by (1) performing electronic  testing of required data elements, (2) reviewing existing information about  the data and the system that produced them, and (3) consulting agency  officials who are knowledgeable about these data. We determined that  these data were sufficiently reliable for the purposes of our reporting  objectives.
Number of providers that participated in the Medicare EHR Program.  To determine the number of providers that participated in the Medicare  EHR Program in 2015, we analyzed data extracted from CMS’s National  Level Repository that represented all successful attestations. CMS  collected these data from January 2016 to March 2016. We counted the  number of unique providers that were included in the 2015 program data  (whom we refer to as “participants”).
Number of program participants who reported two measures related  to patient electronic access to health information. To determine the number of participants who reported two measures related to patient  electronic access to health information, we counted the number of unique  providers who reported a number for (1) the percentage of patients who  were offered the ability to electronically view, download, and transmit their  health information, and (2) the percentage of patients who actually  electronically viewed, downloaded, or transmitted their health information.
The extent to which program participants are offering patients—and  patients are using—the ability to electronically access their health  information. To determine the extent to which program participants  offered patients the ability to electronically access their health information,  we computed the average of the reported percentages of patients who  were offered the ability to view, download, and transmit their health  information by their provider. To determine the extent to which program  participants’ patients actually used the ability to electronically access their  health information, we computed the average of the reported percentage  of patients who actually viewed, downloaded, or transmitted their health  information. To determine the extent to which program participants’  patients actually used the ability to electronically access their health  information when it was available, we divided the number of patients who  actually accessed their health information by the number of patients who  were offered access for each participant, and computed the average.
Characteristics of providers associated with higher or lower  percentages of patients who actually accessed their available health  information. To examine the characteristics of providers that were  associated with higher or lower percentages of patients who actually  accessed their available health information, we analyzed data on provider  characteristics from CMS, the Office of the National Coordinator for  Health Information Technology (ONC), the Health Resources and  Services Administration (HRSA), and the U.S. Census Bureau. Each  characteristic is divided into two or more categories. For example, the  characteristic “geographic region” is divided into four categories— Midwest, Northeast, South, and West regions. As part of this analysis, we  computed the average percentage of patients who actually accessed their  available health information for providers within each characteristic  category without controlling for other characteristics. We examined the  following provider characteristics:  Regional characteristics. We analyzed data on the following regional  characteristics using providers’ business zip code:
Metropolitan status. We used the 2015-2016 HRSA Area Health  Resources File to determine whether providers were located in a  metropolitan area—an area that has at least one urbanized area of  50,000 people, among other criteria. We then categorized providers in  metropolitan areas as being located in urban areas and providers that  were not as being in rural areas.
Geographic region. We used information from the U.S. Census  Bureau to identify the U.S. census region—Midwest, Northeast,  South, or West—where providers were located or practiced.
County residents living in poverty. We used information from the  HRSA Area Health Resources File to calculate the 2014 national  median percentage of counties’ residents living under the poverty line.  We then categorized providers into “higher poverty” areas if they were  located in a county above the national median percentage of residents  living in poverty and “lower poverty” areas if they were located in a  county below or equal to the median.
County residents over age 65. We used information from the HRSA  Area Health Resources File to estimate the 2014 national median of  counties’ percentage of residents over age 65. We then categorized  providers into “higher population over 65” areas if they were located in  a county above the national median percentage of residents over age  65 and “lower population over age 65” areas if they were located in a  county below or equal to the median.
Hospital type. We analyzed data on the following categorizations of  hospital type:
Hospital classification. We determined whether hospitals were  classified as acute care hospitals or critical access hospitals by using  data from CMS’s Hospital Compare file.
Ownership type. We used data on ownership type from CMS’s  Hospital Compare file to create three categories of ownership: (a) for- profit, (b) nonprofit, and (c) government-owned.
Health care professional characteristics. We analyzed data on the  following categorizations of professional characteristics:
Health care professional specialty. We obtained data on  professionals’ primary specialty from CMS’s Physician Compare file.  We then consolidated these specialties into the following three  categories: (a) general practice physician, (b) specialty practice  physician, and (c) other, which includes chiropractors, podiatrists, and  dentists.
Number of health care professionals in the practice. We estimated the  number of professionals in each practice by using data from CMS’s  Physician Compare file. We subsequently created three practice size  categories: (a) practice of 1 to 10 professionals, (b) practice of 11 to  50 professionals, and (c) practice of 51 or more professionals.
section_title: Methodology for Provider Survey
paragraphs: We surveyed a nationally representative sample of providers who  participated in the 2014 Medicare EHR Program about how they are  providing patients with the ability to electronically access health  information.
The survey was designed to collect information from providers related to  patient electronic access to health information, including the methods and  specific technology providers use to give patients electronic access to  their health information, the types of health information providers make  available through these technologies, and any methods providers use to  encourage patient electronic access. The survey was also designed to  capture providers’ perspectives on the benefits of patients having such  electronic access to their health information—specifically whether  providers saw it beneficial for patients to electronically view, download, or  transmit certain types of health information.
The target population for this survey was all hospitals and health care  professionals who reported to the Medicare EHR Program that 5 percent  or more of their patients viewed, downloaded, or transmitted their health  information for the 2014 program year. Using 2014 program data  provided to us by CMS, we identified 60,321 hospitals and health care  professionals to be included in the population for this survey. We selected  a stratified random sample of 1,867 hospitals and providers as described  in table 4 below. We stratified the population by type (hospitals and health care professionals) and the reported percentage of patients who  electronically accessed their health information in 2014. We computed the  sample sizes separately for hospitals and professionals needed to  achieve a precision of plus or minus 5 percentage points or fewer at the  95 percent confidence level. We then increased the sample sizes in each  group for expected response rates of about 50 and 30 percent for  hospitals and health care professionals, respectively. (See table 4.)
A link to this web-based survey was emailed to these 1,867 providers via  the email addresses included in the program data provided by CMS. We  received valid responses from 428 (23 percent) out of the 1,867 hospitals  and health care professionals selected in our stratified random sample.  The weighted response rate, which accounts for the differential sampling  fractions within strata, is 21 percent for the full sample, 28 percent for  hospitals, and 20 percent for health care professionals. (See table 5.)
We conducted an analysis of our survey results to identify potential  sources of nonresponse bias using two methods. First, we examined the  response propensity of the sampled hospitals and health care  professionals by several demographic characteristics. These  characteristics included region, metropolitan status, specialty type, size of  practice, hospital type, and hospital ownership type. Second, we  compared weighted estimates from respondents and nonrespondents to  known population values for measures that are related to the survey  outcomes for which we were most interested. We conducted statistical  tests of differences, at the 95 percent confidence level, between  estimates and known population values, and between respondents and  nonrespondents. These analyses were conducted separately for hospitals  and health care professionals.
Based on this analysis, we did not observe significant differences in  response propensities or between known population values and  estimates for nearly all of the characteristics we examined. However, we  did observe significant differences by ownership type for hospitals and by  region for health care professionals. Specifically, we found that  proprietary and physician-owned hospitals were significantly under- represented by our respondents. Additionally,  we found that professionals  in the Northeast and South were significantly under-represented, while  professionals in the Midwest and West were over-represented by our  respondents.
To ensure that the survey results appropriately represented the  population of 60,321 hospitals and health care professionals, we  weighted the results from the 428 respondents by the inverse of the  probability of selection (base weight) and a nonresponse adjustment  factor to account for nonresponse and the differences in response  propensities we identified. The nonresponse adjustment factor was  calculated using weighting class adjustments where adjustment cells  were based on strata, hospital ownership type, and region.
We repeated the nonresponse bias analysis using the adjusted weights  and found no significant differences with known population and the  weighed estimates for all of the characteristics we examined. This  provided us with evidence that the nonresponse weighting class  adjustments help mitigate any potential nonresponse bias introduced by  the differences in response propensities we identified.
Based on the results of this nonresponse bias analysis and the weighting  adjustments, we determined that weighted estimates generated from  these survey results are generalizable to the population of hospitals and  health care professionals and are sufficiently reliable for the purposes of  this report.
Because we followed a probability procedure based on random  selections, our sample is only one of a large number of samples that we  might have drawn. Since each sample could have provided different  estimates, we express our confidence in the precision of our particular  sample’s results as a 95 percent confidence interval (e.g., plus or minus 7  percentage points). This is the interval that would contain the actual  population value for 95 percent of the samples we could have drawn. As  a result, we are 95 percent confident that each of the confidence intervals  in this report will include the true values in the study population.
section_title: Appendix II: ONC Efforts to Further Patients’ Ability to Access Longitudinal Electronic Health Information
subsections: section_title: Office of the National Coordinator for Health Information Technology (ONC) Effort Blue Button Pledge Program
paragraphs: Voluntary pledge where organizations, such as providers and hospitals, commit to advance efforts  to increase patient access to and use of their health data.  Website to help consumers locate where to find health information online and assist the  development of apps and tools to helps consumers understand and use their health information.  Research designed to understand the experience of stakeholders surrounding patient access to  their own health information and use of electronic health information. The research focuses on  how empathy can help to understand the unmet needs and challenges facing stakeholders.  Educational video for consumers about their right to access their health information.   Intervention aimed at increasing the percentage of patients who enroll in online portals to view,  download, and transmit their health records and communicate online with their clinicians.  Four videos that show how health information technology is being used for patient engagement,  access, and care coordination.   Interactive document that walks providers through strategies they can use to engage patients with  the use of health IT.   Tool that identifies key considerations for adopting health information exchange based on  personal health records.   Infographic regarding an individual’s right to access their medical records (developed and  published in conjunction with the Department of Health and Human Services (HHS) Office for Civil  Rights).   Easy–to–understand videos for consumers, captioned in English and Spanish, about individuals’  right to access their health information under HIPAA, addressing issues including fees and  requesting that health information be sent to a third party (developed and published in conjunction  with the HHS Office for Civil Rights).   Published report on gaps in legal oversight between the collection of electronic health information  regulated by HIPAA  and not regulated by HIPAA  so that consumers can be better aware of the  privacy and security conditions of how they manage their digital health.
Task force to identify priority recommendations for ONC that will help enable consumers to  leverage API  technology to access patient data, while ensuring the appropriate level of privacy  and security protection.  Provides internal and external stakeholders with common connection points to ONC’s standards  and technology efforts. Tech Lab is organized around four areas: 1) standards coordination; 2)  testing and utilities; 3) pilots; and 4) innovation.   Challenge to stimulate consumer-mediated exchange; will help create API solutions to help  individuals securely and electronically authorize the movement of health data to destinations of  their choice.   Challenge to spur the development of third-party consumer-facing applications that use open,  standardized APIs to help consumers aggregate their data in one place.   A working group aimed at developing a set of privacy and security specifications that enable a  consumer to control the authorization of access to RESTful health-related data sharing APIs, and  to facilitate the development of interoperable implementations of these specifications by others.
section_title: Office of the National Coordinator for Health Information Technology (ONC) Effort Patient Engagement Playbook
paragraphs: Tool for health care providers, practice staff, and hospital administrators who want to leverage  health IT using patient portals to engage patients in their health and care.   Update of the 2011 Model Privacy Notice to be more broadly applicable (beyond personal health  records). According to ONC, this update provides open–source content that technology  developers can use to notify consumers of their privacy and security practices.   The 2015 Edition of ONC’s Health IT Certification Criteria supports the certification of health IT,  including APIs, to support patient access to health data and view, download, and transmit  functions that continue to support patient access to their health information, including via both  encrypted and unencrypted email transmission to any third party the patient chooses.   Commitment from health care industry to make electronic health records work better for  consumers and providers.
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Tom Conahan, Assistant  Director; Andrea E. Richardson, Analyst-in-Charge; Marisa Beatley; A.  Elizabeth Dobrenz; and Courtney Liesener made key contributions to this  report. Also contributing were Jim Ashley, Carolyn Fitzgerald, Krister  Friday, Monica Perez-Nelson, and Katie Singh.