As we have reported, the use of information technology (IT) to electronically collect, store, retrieve, and transfer clinical, administrative, and financial health information has great potential to help improve the quality and efficiency of health care and is critical to improving the performance of the U.S. health care system. Critical health information for a patient seeking treatment (such as allergies, current treatments or medications, and prior diagnoses) has, historically, been scattered across paper records kept by many different caregivers in many different locations, making it difficult for a clinician to access all of a patient’s health information at the time of care. Lacking access to these critical data makes it challenging for a clinician to make the most informed decisions on treatment options, potentially putting the patient’s health at greater risk. The use of electronic health records can help provide this access and improve clinical decisions. Electronic health records are particularly crucial for optimizing the health care provided to military personnel and veterans. While in military status and later as veterans, many DOD and VA patients tend to be highly mobile and may have health records residing at multiple medical facilities within and outside the United States. Making such records electronic can help ensure that complete health care information is available for most military service members and veterans at the time and place of care, no matter where it originates. Key to making health care information electronically available is the ability to share that data among health care providers—that is, interoperability. Interoperability is the ability for different information systems or components to exchange information and to use the information that has been exchanged. This capability is important because it allows patients’ electronic health information to move with them from provider to provider, regardless of where the information originated. If electronic health records conform to interoperability standards, they can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization, thus providing patients and their caregivers the necessary information required for optimal care. (Paper-based health records—if available—also provide necessary information, but unlike electronic health records, paper records do not provide decision support capabilities, such as automatic alerts about a particular patient’s health, or other advantages of automation.) Interoperability can be achieved at different levels. At the highest level, data are in a format that a computer can understand and operate on, whereas at the minimum type of interoperability, the data are in a format that is viewable, so that information is available for a human being to read and interpret. Figure 1 shows various levels of interoperability and examples of the types of data that can be shared at each level. As the figure shows, paper records can be considered interoperable in that they allow data to be read and interpreted by a human being. In the remainder of this report, however, we do not discuss interoperability in this sense; instead, we focus on electronic interoperability, for which the first level of interoperability is unstructured, viewable electronic data. With unstructured data, a clinician would have to find needed or relevant information by scanning uncategorized information. The value of viewable data is increased if the data are structured so that information is categorized and easier to find. At the highest level, as shown, the computer can interpret and act on the data. Not all data require the same level of interoperability. For example, in their initial efforts to implement computable data, VA and DOD focused on outpatient pharmacy and drug allergy data because clinicians gave priority to the need for automated alerts to help medical personnel avoid administering inappropriate drugs to patients. On the other hand, for such narrative data as clinical notes, viewability may be sufficient. Achieving even a minimal level of interoperability is valuable for potentially making all relevant information available to clinicians. Any type of interoperability depends on the use of agreed-upon standards to ensure that information can be shared and used. In health IT, standards govern areas ranging from technical issues, such as file types and interchange systems, to content issues, such as medical terminology. Developing, coordinating, and agreeing on standards are only part of the processes involved in achieving interoperability for electronic health records systems or capabilities. In addition, specifications are needed for implementing the standards, as well as criteria and a process for verifying compliance with the standards. In December 2001, an effort to establish federal health information standards was initiated as an Office of Management and Budget (OMB) e- government project to enable federal agencies to build interoperable health data systems. This project, the Consolidated Health Informatics initiative, was a collaborative agreement among federal agencies, including DOD and VA, to adopt a common set of health information standards for the electronic exchange of clinical health information. Under the Consolidated Health Informatics initiative, DOD, VA, and other participating agencies agreed to endorse 20 sets of standards to make it easier for information to be shared across agencies and to serve as a model for the private sector. For example, standard medication terminologies were agreed upon, which DOD and VA then began to adopt in developing their data repositories. Recognizing the need for public and private sector collaboration to achieve a national interoperable health IT infrastructure, the President issued an executive order in April 2004 that called for widespread adoption of interoperable electronic health records by 2014. This order established the Office of the National Coordinator for Health Information Technology within the Department of Health and Human Services (HHS) with responsibility, among other things, for developing, maintaining, and directing the implementation of a strategic plan to guide the nationwide implementation of interoperable health IT in both the public and private health care sectors. Among its responsibilities as the chief advisor to the Secretary of HHS in this area, the Office of the National Coordinator is to report progress on the implementation of this strategic plan. Under the direction of HHS (through the Office of the National Coordinator), three primary organizations were designated to play major roles in expanding the implementation of health IT: the American Health Information Community, the Healthcare Information Technology Standards Panel, and the Certification Commission for Healthcare Information Technology. All three are involved in various processes related to electronic health records interoperability standards. The functions of these organizations are described in the following. The community is a federal advisory body created by the Secretary of HHS to make recommendations on how to accelerate the development and adoption of health IT, including advancing interoperability, identifying health IT standards, advancing nationwide health information exchange, and protecting personal health information. Formed in September 2005, the community is made up of representatives from both the public and private sectors. The American Health Information Community determines specific health care areas of high priority and develops “use cases” for these areas, which provide the context in which standards would be applicable. For example, the community has developed a use case regarding the creation of standardized, secure records of past and current laboratory test results for access by health professionals. The use case conveys how health care professionals would use such records and what standards would apply. Developed in October 2005, the Healthcare Information Technology Standards Panel (HITSP) is a public-private partnership, sponsored by the American National Standards Institute and funded by the Office of the National Coordinator. (HITSP is the successor to the Consolidated Health Informatics initiative, which was dissolved and absorbed into the panel on September 30, 2006.) The panel was established to identify competing standards for the use cases developed by the American Health Information Community and “harmonize” the standards. (Harmonization is the process of identifying overlaps and gaps in relevant standards and developing recommendations to address these overlaps and gaps.) For example, for the three initial use cases developed by the American Health Information Community, HITSP identified competing standards by converting the use cases into detailed requirements documents; it then examined and assessed more than 700 existing standards that would meet those requirements. From those 700 standards, the panel identified 30 named standards and produced detailed implementation guidance describing the specific transactions and use of these named standards. This guidance is codified in an interoperability specification for each use case that integrates the standards. Each of the interoperability specifications developed by HITSP includes references to the identified standards or parts of standards and explains how they should be applied to specific topics. For example, among the standards referred to in one interoperability specification is the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT). This standard is to be used in the “Lab Result Terminology Component” of the specification. Once developed, the specifications are presented to the American Health Information Community, which assesses them for recommendation to the Secretary of HHS. The Secretary publicly “accepts” recommended specifications for a 1-year period of implementation testing, after which the Secretary can formally “recognize” the specifications and associated guidance as interoperability standards. This two-step process is intended to ensure that software developers have adequate time to implement recognized standards in their software. The year between acceptance and recognition allows the panel to refine its implementation guidance based on feedback from actual software implementation. Table 1 shows the current status of the interoperability specifications developed by HITSP. Each of the interoperability specifications in the table is associated with one of the seven use cases developed by the American Health Information Community in 2006 and 2007. The community is also developing six use cases for 2008, for which interoperability specifications have not yet been released: Consultation and Transfers of Care, Public Health Case Reporting, and Immunizations & Response Management. The commission is an independent, nonprofit organization that certifies health IT products. HHS entered into a contract with the commission in October 2005 to develop and evaluate the certification criteria and inspection process for electronic health records. According to HHS, certification is to be the process by which the IT systems of federal health contractors are established to meet federal interoperability standards.