ONC defines an EHR as a digital version of a medical record that can include a person’s medical and treatment history, such as diagnoses, medications, treatment plans, and more. According to ONC, EHR systems also can allow access to evidence-based tools that providers use to make decisions about a person’s care, and they can automate and streamline provider workflow. ONC states that one of the key potential benefits of an EHR is that it can allow health information to be created and managed in a digital format capable of being shared with other providers across more than one health care organization. This exchange may occur between hospitals, primary care physicians, specialty physicians, pharmacies, laboratories, and post-acute care providers. (See fig. 1.) Even when providers adopt an EHR system, they may not be able to use that system to exchange health information with other providers, and the EHR systems will not necessarily be interoperable with other health IT systems, including EHRs and health IT systems belonging to laboratories, specialists, and post-acute care settings. When EHR systems are interoperable, information can be exchanged—sent from one provider to another—and then seamlessly integrated into the receiving provider’s EHR system, allowing the provider to use that health information to inform clinical care. We previously reported that EHR systems often use different formats and terminology while exchanging health information, which limits interoperability. We also reported that the electronic exchange of health information and interoperability relies, in part, on business arrangements between health care providers who must agree on the rules for exchange, without which the ability to exchange information may be hampered. As a result, even when health information can be exchanged electronically, there is no guarantee that the information can and will be automatically integrated into the receiving system, and therefore the EHR systems may not be interoperable. ONC has studied the extent to which non-federal acute care hospitals performed tasks that demonstrate the ability to be interoperable. In particular, for 2015 ONC reported the percentage of surveyed hospitals electronically sending (85 percent), receiving (65 percent), finding (52 percent), and using or integrating key clinical information (38 percent). According to ONC, even fewer hospitals—about 25 percent—performed all four of these tasks. Health care providers can use different mechanisms for the electronic exchange of health care information. For example, if two providers’ EHR systems are interoperable with each other, then the providers can electronically share information directly from one provider’s EHR system to the other provider’s EHR system. Another mechanism is Direct, which is a set of specifications that allows users to send secure messages, including documents, to known and trusted recipients over the internet. With Direct, one health care provider can electronically transmit documents with health information to another. However, the provider may send documents with information in a format that is difficult for the receiving provider to access and consider in a timely or efficient manner, which can limit the ability to ensure coordination of care and avoid errors. Another way of electronically exchanging health information is through health information exchange (HIE) organizations, which are entities that bring together health care stakeholders within a defined geographic area to share health information. An HIE organization can facilitate the electronic exchange of health information by providing data connections among stakeholders, such as laboratories, public health departments, hospitals, and physicians. We previously identified some concerns associated with HIEs, including costs. One of the ways to standardize the information that acute care facilities and other providers may exchange electronically is by using the Consolidated-Clinical Document Architecture (C-CDA). It provides a common structure for sharing information and was developed to help providers manage a complex set of documents and reduce duplicative and conflicting standards issued by different organizations. The C-CDA contains more than 150 templates for information such as allergies, medications, plan of care, social history, vital signs, functional status, family history, and more. HHS has implemented a series of actions designed to increase the use of health IT in general and the use of EHRs and electronic exchange of health information specifically in post-acute care settings. CMS requires providers in each of four different types of post-acute facilities—specifically skilled nursing facilities, inpatient rehabilitation facilities, home health agencies, and long-term care hospitals—to report certain data that are used for quality measures, resource use measures, and other types of measures. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 requires, among other things, the standardization of those data elements—or specific pieces of data—that providers must report to CMS. Under the IMPACT Act, these data elements should be standardized in a way that allows for the exchange of data among post-acute care settings and providers. The first of these data elements required to be standardized for submission include data on patients’ functional status, skin integrity (such as pressure ulcers), and incidence of major falls. ONC released the most recent strategic plan for health IT in September 2015, outlining four primary goals, each with its own objectives, for using health IT to improve the health and well-being of individuals and communities. One of those goals is to enhance and modernize the nation’s health IT infrastructure. ONC’s Shared Nationwide Interoperability Roadmap (Roadmap), established in 2015, aligns with this goal in the strategic plan. The Roadmap is a planning document that proposes specific actions to achieve an interoperable health IT system nationwide that collectively improves health. The Roadmap includes plans for the infrastructure needed to support the sharing and use of electronic health information. The Roadmap includes a specific goal to increase the proportion of post-acute care providers electronically exchanging health information. This Roadmap goal relates to the HHS strategic plan goal of enhancing health IT infrastructure. The strategic plan also notes that post-acute care settings require access to patient information to ensure continuity of care and prevent adverse events, such as medication allergies or errors. ONC authorizes certification bodies to (on its behalf) certify whether health IT, including EHR systems, meet certain functional and technical requirements and conform to standards and implementation specifications. Certified EHR technology helps assure purchasers and other users that an EHR meets the technological and functional requirements adopted by HHS. Providers that participate in the Medicare and Medicaid EHR Incentive Programs (which do not include post-acute care providers) must demonstrate that they are meaningful users of certified EHR technology. CMS officials noted that EHR selection is provider specific and that CMS has no authority to demand which EHR system is used by post-acute care providers. We identified five key factors that affect the use of EHRs and the electronic exchange of health information in post-acute care settings, based on our stakeholder interviews: (1) the cost of EHRs, (2) implementation of standards for EHRs and electronic health information exchange, (3) the impact of EHRs on workflow, (4) technological challenges such as lack of EHR capabilities, and (5) the need to train staff to use EHRs. Cost: All 20 stakeholders we interviewed described the cost of EHRs and related technology as a key factor discouraging post-acute care providers from obtaining EHRs and exchanging health information electronically. According to a survey of care providers in New York, the costs associated with the adoption of EHRs in long-term and post-acute care settings varied significantly. Two-thirds of the surveyed providers reported that they spent more than $100,000 on EHRs, and nearly 20 percent reported spending more than $500,000. In addition to the high cost of the initial purchase of EHR software, stakeholders indicated that post-acute care providers must also often purchase additional software modules so that their EHRs can be used to send health information electronically, which is considered a more advanced function. Furthermore, stakeholders told us that the additional fees for maintaining an EHR can add more costs in addition to fees associated with adding the capability to exchange health information electronically. For example, one stakeholder noted the costs of connecting EHRs to allow them to be interoperable with other facilities’ EHRs and ongoing maintenance fees that some vendors charge can be more challenging to pay for than the initial purchase of the EHR. We previously reported on similar experiences among acute care providers, who expressed challenges with the upfront costs associated with purchasing and implementing EHRs, as well as with fees for participating in state and local HIEs and per-transaction fees for exchanging health information. According to stakeholders, these costs are particularly challenging in cases when post-acute care providers have small profit margins and may therefore not have the financial resources to purchase EHR technology. For example, one stakeholder stated that post-acute care providers struggling financially will only invest in EHR systems if they have an incentive to do so, such as the promise of receiving more patient referrals. Stakeholders also noted that post-acute care settings did not receive federal incentives for meaningful use of EHRs aimed at acute-care hospitals and other providers. Without financial incentives, or a mandate to adopt EHR technology, there is no business case for post-acute care providers to adopt EHR technology, several stakeholders told us. According to stakeholders, post-acute facilities generally do not see an immediate financial benefit from adopting or using EHRs, because purchasing and implementing an EHR is expensive and challenging, and post-acute facilities are not eligible for financial incentives. As a result, providers may not perceive that the value of an EHR is worth the cost, and they are less likely to use EHRs. In addition, stakeholders stated that purchasing an EHR does not result in more revenue for the provider.