Health Information Technology: HHS Is Taking Steps to Develop a  
National Strategy (27-MAY-05, GAO-05-628).			 
                                                                 
To prevent medical errors, reduce costs, improve quality, and	 
produce greater value for health care expenditures, President	 
Bush has called for the Department of Health and Human Services  
(HHS) to develop and implement a strategic plan to guide the	 
nationwide implementation of health information technology (IT)  
in both the public and private health care sectors. The 	 
Departments of Defense (DOD) and Veterans Affairs (VA), along	 
with other countries, have already taken steps to improve health 
care delivery and administration by implementing IT solutions.	 
GAO was asked to provide an overview of HHS's recent efforts to  
develop a national health IT strategy for realizing the 	 
President's vision, and to identify lessons learned from DOD's,  
VA's, and other countries' experiences in implementing health IT.
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-628 					        
    ACCNO:   A25325						        
  TITLE:     Health Information Technology: HHS Is Taking Steps to    
Develop a National Strategy					 
     DATE:   05/27/2005 
  SUBJECT:   Information technology				 
	     Interagency relations				 
	     Lessons learned					 
	     Medical information systems			 
	     Strategic planning 				 
	     Strategic information systems planning		 
	     Standards						 
	     Information systems				 

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GAO-05-628

United States Government Accountability Office

GAO	Report to the Chairman, Committee on the Budget, House of
Representatives

May 2005

HEALTH INFORMATION TECHNOLOGY

               HHS Is Taking Steps to Develop a National Strategy

                                       a

GAO-05-628

[IMG]

May 2005

HEALTH INFORMATION TECHNOLOGY

HHS Is Taking Steps to Develop a National Strategy

                                 What GAO Found

The Secretary of HHS appointed the National Coordinator for Health IT in
May 2004. In July 2004, the national coordinator released a framework for
strategic action, which outlines four goals and 12 strategies to guide the
development of a full strategic plan for national health IT adoption (see
table below). The framework builds upon already-existing work in federal
health IT and includes plans to identify and learn from agencies'
experiences. It also describes actions to be taken by both the public and
private sectors to achieve interoperability in health IT across the
nation.

HHS plans to address the goals and strategies of the framework with a
threephased approach over a number of years and is currently implementing
phase I of the framework. However, HHS has not established milestones for
the completion of phase I activities nor has it made detailed plans or set
milestones for the completion of activities for phases II and III.

Goals and Strategies of HHS's Framework for Strategic Action

1. Incentivize EHR adoption Goal 1: Inform clinical practice with 2.
Reduce risk of EHR investment the use of electronic health records 3.
Promote EHR diffusion in rural and underserved (EHR) areas Goal 2:
Interconnect clinicians so that they can exchange health information using
advanced and secure electronic communication

1. Foster regional collaboration

2. Develop a national health information network

3. Coordinate federal health information systems

Goal 3: Personalize care with consumer-based health records and better
information for consumers

1. Encourage use of personal health records

2. Enhance informed consumer choice

3. Promote use of telehealth systems

Goal 4: Improve public health through
advanced biosurveillance methods and 1. Unify public health surveillance
architectures
streamlined collection of data for 2. Streamline quality and health status
monitoring
quality measurement and research 3. Accelerate research and dissemination
of evidence

Source: HHS.

a

Phase I strategies are shown in bold type.

GAO identified lessons learned from DOD and VA that could provide valuable
insight to HHS as it works toward implementing a national health IT
infrastructure. DOD and VA operate the largest health care delivery
networks in the nation, and important lessons can be taken from their
experiences in health IT. Additionally, other countries have begun
initiatives to establish national health IT infrastructures. DOD, VA,
Canada, Denmark, and New Zealand provided GAO with valuable lessons
learned that can be applied to the United States's efforts. Among other
lessons learned, they reported the need to

o  obtain the endorsement of top leadership,

o  define and adopt standards,

o  address the needs of stakeholders, and

o  deploy IT solutions in small increments and build on successes.

                 United States Government Accountability Office

Contents

Letter 1 Recommendation for Executive Action 4 Agency Comments 4

Appendixes

Appendix I:          National Health Information Technology Strategy     6 
Appendix II:        Comments from the Department of Health and Human 
                                                               Services    84 
      Appendix III:    Comments from the Department of Veterans Affairs    88 

Abbreviations

AHRQ Agency for Health Research and Quality
CDC Centers for Disease Control and Prevention
CHI Consolidated Health Informatics
CMS Centers for Medicare and Medicaid Services
DOD Department of Defense
EHR electronic health records
FDA Food and Drug Administration
FHA Federal Health Architecture
HHS Department of Health and Human Services
HRSA Health Resources and Services Administration
IHS Indian Health Service
IT information technology
NCVHS National Committee on Vital and Health Statistics
NHIN National Health Information Network
NIH National Institutes of Health
ONCHIT Office of the National Coordinator for Health IT
VA Department of Veterans Affairs

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
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copyright holder may be necessary if you wish to reproduce this material
separately.

A

United States Government Accountability Office Washington, D.C. 20548

May 27, 2005

The Honorable Jim Nussle Chairman, Committee on the Budget House of
Representatives

Dear Mr. Chairman:

According to the Institute of Medicine, health care delivery in the United
States has long-standing problems with medical errors and inefficiencies
that increase health care costs. The U.S. health care delivery system is
an information-intensive industry that is complex and highly fragmented
with estimated spending of $1.7 trillion in 2003. In April 2004, President
Bush announced a health information technology (IT) plan that calls for
the development and implementation of a strategic plan to guide the
nationwide implementation of health IT in both the public and private
health care sectors to prevent medical errors, improve quality, and
produce greater value for health care expenditures.

Also in April 2004, the President issued an executive order that required
the Secretary of Health and Human Services to appoint a national
coordinator whose role is to provide leadership for the development and
nationwide implementation of an interoperable health IT infrastructure to
improve the quality and efficiency of health care. The National
Coordinator for Health IT was appointed in May 2004; in July 2004, the
coordinator released a framework for strategic action, the first step
toward a national strategy. The framework builds upon already-existing
work in federal health IT and includes plans to identify and learn from
agencies' experiences, including those of the Departments of Defense (DOD)
and Veterans Affairs (VA), which operate the largest health care delivery
networks in the nation and have experience with developing and
implementing IT solutions throughout their systems. Additionally, other
countries have begun to develop and implement strategies to improve health
care delivery through the nationwide adoption of IT and can provide
valuable lessons for the Department of Health and Human Services (HHS).

You asked us to (1) provide an overview of HHS's efforts to develop and
implement a national health IT strategy, (2) identify lessons learned from
DOD's and VA's experiences with implementing electronic health records,
and (3) identify lessons learned from other countries' efforts to
modernize health IT infrastructures. We conducted work at HHS, DOD, and
VA-the federal agencies that play major roles in supporting and providing
health

care delivery in the United States and that are promoting the use of
health IT. We reviewed and assessed HHS's framework and plans for
developing a national health IT strategy to understand the role of the new
office for national coordination of health IT. We supplemented our
assessment by discussing with officials throughout the department their
involvement in national efforts to implement health IT and the integration
of current health IT initiatives into the national strategy. We analyzed
DOD and VA documentation and prior GAO reports discussing the two
departments' implementation of health IT (see app. I). We supplemented our
analyses by discussing with DOD and VA officials the lessons that they
learned from implementing health IT solutions in two of their major
information systems. We selected examples of other countries' efforts to
modernize health IT infrastructures based upon literature reviews and
discussions with health care IT experts. We discussed with Canada,
Denmark, and New Zealand their initiatives to modernize national health IT
infrastructures and identified lessons learned from their experiences that
could be meaningful to the United States's efforts. We conducted our work
from October 2004 through March 2005, in accordance with generally
accepted government auditing standards.

On April 1, 2005, we provided your office with a briefing on the results
of this review. The purpose of this letter is to provide the published
briefing slides to you, which appear as appendix I. The information in
these slides has been updated to include additional information requested
by your office.

In summary, we found that HHS, through the Office of the National
Coordinator for Health IT, is taking initial steps toward developing a
national strategy for health IT and has released a framework that
describes actions to be taken by the public and private sectors to develop
and implement such a strategy. The framework defines goals and strategies
that are to be implemented in three phases. Phase I focuses on the
development of market institutions1 to lower the risk of health IT
procurement, phase II involves investment in clinical management tools and
capabilities, and phase III supports the transition of the market to
robust quality and performance accountability.

1According to HHS, market institutions include certification
organizations, group purchasing entities, and low-cost implementation
support organizations that do not currently exist but are necessary to
support clinicians as they procure and use IT.

HHS is in the initial phase of implementing activities to achieve the
goals of the framework and, as a result, has made progress toward
coordinating federal health IT efforts and reaching out to private
industry. For example, in November 2004, the department issued a request
for information seeking public input and ideas for developing a national
health information network; a task force of federal agencies is evaluating
over 500 responses to this request. HHS is also working with the private
sector to develop standards and certification procedures for health IT
interoperability. However, HHS has not established milestones for the
completion of phase I, nor has it defined plans for phases II and III.
Without defined milestones, it remains unclear when the important
activities of phase I will be completed to provide the building blocks
needed to support the activities of the subsequent phases.

We identified lessons learned from DOD and VA that could provide valuable
insight to HHS as it works toward implementing a national health IT
infrastructure. DOD and VA operate the largest health care delivery
networks in the nation, and important lessons can be taken from their
experiences in health IT. Among other things, they reported the need to

o  obtain full endorsement of top leadership,

o  define and adopt common standards and terminology,

o 	recognize and address the needs of the varied stakeholder communities,
and

o  deploy in small increments and build on success.

We also reported additional lessons learned from other countries'
experiences in modernizing health IT infrastructures. Canada, Denmark, and
New Zealand have begun initiatives to establish national health IT
infrastructures with government support and identified lessons learned
from their experiences, such as

o  focus on creating standards first,

o  establish a central organization to lead health IT efforts, and

o  implement solutions incrementally.

Recommendation for 	As a result of our work, we recommend that the
Secretary of Health and Human Services establish detailed plans and
milestones for each phase of

Executive Action	the framework for strategic action and take steps to
ensure that those plans are followed and milestones are met.

Agency Comments	We received written comments on a draft of this report
from the Acting Inspector General at HHS and the Deputy Secretary of VA.
We received oral comments from the Chief Enterprise Architect for Military
Health System at DOD. DOD, HHS, and VA concurred with our results and
provided technical comments, which we have incorporated in this report as
appropriate. HHS agreed with our recommendation and described additional
actions that the Secretary is taking to achieve specific goals of the
framework and to benefit from lessons learned from DOD and VA. HHS also
provided additional information about the steps that the department is
taking to lead the nation in health IT efforts. This information is
provided in HHS's written comments, which are reproduced in appendix II.
VA's written comments are reproduced in appendix III.

We are sending copies of this report to the Chairmen and Ranking Minority
Members of other Senate and House committees and subcommittees having
authorization and oversight responsibilities for health care IT. We are
also sending copies to the Secretary of Health and Human Services and to
the other agencies that participated in our review. We will also make
copies available to others upon request. In addition, the report will be
available at no charge on the GAO Web site at http://www.gao.gov.

Should you or your office have any questions about matters discussed in
this report, please contact Dave Powner at (202) 512-9286 or by e-mail at
[email protected]. Contact points for our Offices of Congressional Relations
and Public Affairs may be found on the last page of this report. Major
contributors to this report also included Tonia D. Brown, Pamlutricia
Greenleaf, M. Saad Khan, Valerie C. Melvin, M. Yvonne Sanchez, Teresa F.
Tucker, and Jessica D. Waselkow.

Sincerely yours,

David A. Powner Director, Information Technology

Management Issues

Linda D. Koontz Director, Information Management Issues

Appendix I

National Health Information Technology Strategy

                          National Health Information
                              Technology Strategy

                          Briefing for Majority Staff
                            Committee on the Budget
                            House of Representatives

                                 April 1, 2005

Updated

Appendix I
National Health Information Technology
Strategy

                               Table of Contents

                                      Page

o  Introduction 3

o  Objectives, Scope, and Methodology 4

o  Results in Brief 8

o  Background 10

o  National Health Information Technology Strategy 27

o 	Lessons Learned from the Departments of
Defense and Veterans Affairs 52

o  Lessons Learned from Other Countries 57

o  Conclusions 67

o  Recommendation 69

o  Agency Comments 70

o  Appendixes 71

Appendix I
National Health Information Technology
Strategy

                                  Introduction

o 	The United States health care delivery system is an
information-intensive industry that is complex, inefficient, and highly
fragmented, with estimated spending of $1.7 trillion in 2003.

o 	Calling for transformational change in the health care industry, the
Institute of Medicine pointed out that health care delivery in the United
States has longstanding problems with medical errors and inefficiencies
that increase the cost of health care.1

o 	The President's health care information technology (IT) plan calls for
the development and implementation of a strategic plan to guide the
nationwide implementation of interoperable health information technology
in both the public and private health care sectors that will prevent
medical errors, reduce costs, improve quality, and produce greater value
for health care expenditures.

.

Appendix I
National Health Information Technology
Strategy

                       Objectives, Scope and Methodology

                              Objectives and Scope

Objectives

o 	To provide an overview of the Department of Health and Human Services'
(HHS) efforts to develop and implement a national health information
technology strategy

o 	To identify lessons learned from the Departments of Defense's (DOD) and
Veterans Affairs' (VA) implementation of electronic health records (EHRs)

o 	To identify lessons learned from other countries' efforts to modernize
health IT infrastructures

Appendix I
National Health Information Technology
Strategy

                       Objectives, Scope and Methodology

                              Objectives and Scope

Scope

o 	Conducted work at HHS components that play major roles in supporting
health care IT, including the Agency for Healthcare Research and Quality,
Centers for Medicare and Medicaid Services, Food and Drug Administration,
Health Resources and Services Administration, Indian Health Service,
National Institutes for Health, and Office of the National Coordinator for
Health IT in Washington, D.C., and the Centers for Disease Control and
Prevention in Atlanta, GA

o 	Conducted work at DOD's Office of Health Affairs in Falls Church, VA
and VA's Veterans Health Administration in Washington, D.C.

o 	Selected and reviewed examples of health care IT infrastructure
initiatives from Canada, Denmark, New Zealand, and the United Kingdom.

Appendix I
National Health Information Technology
Strategy

                       Objectives, Scope and Methodology

                                  Methodology

o 	Reviewed HHS's framework and implementation plans for developing a
national health IT strategy and held discussions with agency officials
about their involvement in national efforts to implement health IT and the
integration of current health IT initiatives into the national strategy

o 	Analyzed agency documentation and GAO reports discussing DOD's and VA's
implementation of EHRs as part of the Composite Health Care System II and
the Veterans Health Information System and Technology Architecture

o 	Supplemented analyses with interviews of DOD and VA officials regarding
the agencies' practices, processes, and outcomes in implementing EHRs, and
identified related lessons learned that could be useful in the
implementation of a national health care system

o 	Consulted with a private health care consultant currently studying EHRs
to assess the validity of the identified lessons and their applicability
in federal and private health care settings

Appendix I
National Health Information Technology
Strategy

                 Objectives, Scope and Methodology Methodology

o 	Conducted literature reviews of other countries' efforts to implement
health IT and held discussions with officials in Canada, Denmark, and New
Zealand to gain information about experiences related to costs, benefits,
time frames, and challenges

o 	We held discussions with health care IT experts and reviewed literature
to identify countries that are modernizing health IT infrastructures and
were willing to discuss their initiatives and lessons learned with us.

o 	We obtained information about the United Kingdom's health IT
modernization project by reviewing publicly available documentation.

o 	We conducted our work from October 2004 through March 2005 in
accordance with generally accepted government auditing standards.

o 	We collected systems descriptions and cost information from agency
officials and did not independently verify data provided to us.

o 	We requested comments from HHS, DOD, and VA on a draft of these
briefing slides.

Appendix I
National Health Information Technology
Strategy

                                Results in Brief

o 	In July 2004, HHS delivered a framework for strategic actions as a
first step toward a strategy to implement a nationwide health IT
infrastructure that involves both the public and private sectors'
participation.

o 	The framework builds upon ongoing work in federal health IT and
includes plans to identify and learn from agencies' experiences.

o 	The framework defines goals and strategies which are to be implemented
in three-phases.

o 	HHS is in the initial phase of implementing the framework's strategies
but has not defined milestones for completion of this phase or later
phases.

o 	In November 2004, HHS issued a request for information seeking public
input and ideas for developing a national health information network; a
task force of federal agencies is evaluating over 500 responses.

Appendix I
National Health Information Technology
Strategy

                                Results in Brief

o 	DOD and VA operate the largest health care delivery networks in the
nation, and their experiences in implementing EHRs offer important lessons
learned that could be applied to a national health records system. These
lessons include:

o  Obtain full endorsement of top leadership

o  Define and adopt common standards and terminology

o  Recognize and address needs of the varied stakeholder communities

o  Deploy in small increments and build on success

o 	Other countries have begun initiatives to establish national health IT
infrastructures with government support and also provided valuable lessons
learned that can be applied to the U.S.'s efforts, such as:

o  Focus on creating standards first

o  Establish a central organization to lead health IT efforts

o  Implement incrementally

o 	As a result of our review, we recommend that HHS establish plans and
milestones for fully implementing its framework for strategic action.

Appendix I
National Health Information Technology
Strategy

                                   Background

IT in the Health Care Industry

o 	The President's Information Technology Advisory Committee2 observed
that, unlike most industries in which IT has improved efficiency, quality,
and productivity, health care still operates using primarily paper-based
records, phone calls, faxes, and mail.

o 	Unlike the nationalized health systems of many countries, the U.S.
health care system is composed of private, independent hospitals,
ambulatory care and long-term care facilities, and private individual and
group provider practices.

o 	The free market system does not inherently generate practical
mechanisms for sharing information critical to patient care.

o 	According to HHS, health care is the largest sector of the economy that
has not fully embraced information technology.

2 The President's Information Technology Advisory Committee's members are
appointed by the President to provide independent expert advice on IT.

Appendix I
National Health Information Technology
Strategy

                   Background IT in the Health Care Industry

o 	Health IT is used to support health care quality and efficiency by
providing tools to improve patient care and to reduce administration
overhead. For example

o 	Electronic health records (EHRs)3 provide patients and their caregivers
the necessary information required for optimal care while reducing costs
and administrative overhead, such as that associated with patient
registration, admission, discharge, and billing.

o 	Computer-assisted clinical decision support tools increase the ability
of health care providers to take advantage of current medical knowledge
from online medical references as they make treatment decisions.

o 	Computerized provider order entry allows providers to electronically
order tests, medicine, and procedures for patients, reducing errors
associated with hand-written orders and prescriptions.

o  Telehealth is used to provide health care to rural and remote areas .

through the use of communications technologies.

3 There is a lack of consensus on what constitutes an EHR, and thus
multiple definitions and names exist for EHRs, depending on the functions
included. An EHR generally includes (1) a longitudinal collection of
electronic health information about the health of an individual or the
care 11 provided, (2) immediate electronic access to patient-and
population-level information by authorized users, (3) decision support to
enhance the quality, safety, and efficiency of patient care, and (4)
support of efficient processes for health care delivery.

Appendix I
National Health Information Technology
Strategy

                                   Background

IT Adoption Rates in Health Care

o 	We recently reported that current health IT adoption rates in the
United States are varied and increasing the rates of IT adoption is
critical to achieving significant benefits.4

o 	Respondents to a recent survey conducted by the Medical Group
Management Association reported that only 31 percent of physician group
practices use fully operational EHRs.

o 	The Healthcare Information and Management Systems Society reported that
19 percent of hospitals use fully operational EHRs.

o 	According to a study by the Commonwealth Fund, approximately 13 percent
of solo physicians have adopted some form of EHR, while 57 percent of
large group practices (50 or more physicians) have adopted an EHR.

o 	According to the Commonwealth Fund, gaps in adoption rates are further
widened by barriers and challenges to implementing health IT that are
greater for solo and small group practices.

Appendix I
National Health Information Technology
Strategy

                                   Background

Challenges to Implementing IT

o 	While there are proven benefits to implementing health IT, the Medicare
Payment Advisory Commission5 identified other factors that present
financial, technical, and cultural challenges.

o 	Investment in IT can be costly and must compete with other investments,
and depends on the organization's ability to access capital.

o 	Integrating new IT with other systems can further increase costs and
system maintenance requirements.

o 	Maintaining full operations when making system changes presents
additional challenges.

o 	Implementation of IT often requires changes in work processes and
culture.

o 	Physicians' reluctance is a major hurdle to implementing IT, and
overcoming it is key to successful projects.

Appendix I
National Health Information Technology
Strategy

                                   Background

                Recent Studies on Cost and Benefits of Health IT

o 	Studies by the Center for Information Technology Leadership identified
savings from the widespread adoption of health IT.

o 	The Value of Healthcare Information Exchange and Interoperability
identified $78 billion in annual savings based on electronically sharing
health care data between providers and stakeholders, which resulted in
saving time and avoiding duplicate tests.

o 	The Value of Computerized Provider Order Entry in Ambulatory Settings
estimated $44 billion in annual savings based on avoidance of unnecessary
outpatient visits and hospital admissions, as well as more cost-effective
medication, radiology, and lab ordering.

o 	The center and other health care experts acknowledge that these
estimates are based on limited data and a number of assumptions and,
therefore, are not necessarily complete and precise.

o 	In October 2003, we reported significant financial benefits realized
from the implementation of health IT, including cost savings at VA and
expected savings at DOD (GAO-04-224; see appendix I).

Appendix I
National Health Information Technology
Strategy

                                   Background

Administration's Health IT Agenda

o 	The President's health care IT plan calls for the widespread adoption
of interoperable EHRs within 10 years.

o 	In April 2004, the President issued Executive Order 133356 to "provide
leadership for the development and nationwide implementation of an
interoperable health information technology infrastructure to improve the
quality and efficiency of health care." Among other things, the order
called for

o 	the appointment of a national coordinator for health IT who is to
report to the Secretary of HHS regarding progress on the development and
implementation of a strategic plan.

o 	The Secretary appointed a national coordinator in May 2004 whose
responsibilities include coordination of programs and policies regarding
health IT across the federal government, and outreach and consultation
between the federal government and the private sector.

Appendix I
National Health Information Technology
Strategy

                                   Background

                            HHS's Role in Health IT

o 	As a regulator, purchaser, health care provider, and sponsor of
research, HHS is taking steps to promote the use of IT in public and
private health care settings.

o 	The Agency for Healthcare Research and Quality (AHRQ) aims to translate
research findings into better patient care and provides funding for state
and regional IT demonstration projects and a national resource center for
grantees and organizations that are engaged in health IT activities.

o 	According to HHS officials, over half of AHRQ's funding goes to rural
and small communities.

o 	The Centers for Medicare and Medicaid Services (CMS) administers the
Medicare program and works in partnership with states to administer the
Medicaid program and the States Children's Health Insurance Program; CMS
has established pilots to promote the adoption and effective use of health
IT in physicians' offices and to improve beneficiary telephone customer
service using web-based call centers.

Appendix I
National Health Information Technology
Strategy

                                   Background

                            HHS's Role in Health IT

o 	Indian Health Service (IHS) provides health services to American
Indians and Alaskan Natives and reportedly uses a hospital information
system that provides order entry, results reporting, encounter
documentation, and other clinical functions.

o 	The Health Resources and Services Administration (HRSA) aims to expand
access to high-quality health care and provide grants for community-based
activities in informatics, EHRs, and telehealth.

o 	HRSA awarded 65 grants and over $30 million for telehealth in 2004.

o 	The National Institutes of Health (NIH) works to apply scientific
knowledge to extend healthy life and provide research grants for computer
technologies to facilitate access, storage, and use of biomedical
information, for training of informatics researchers and developers, and
access to informatics resources.

Appendix I
National Health Information Technology
Strategy

                                   Background
                                  Role of the
               National Committee on Vital and Health Statistics

o 	The National Committee on Vital and Health Statistics (NCVHS) was
established in 1949 as a public advisory committee that is statutorily
authorized to advise the Secretary of HHS on health data, statistics, and
national health information policy, including the implementation of health
IT standards.

o 	The committee is responsible for developing recommendations to HHS for
standards to enable e-prescribing and delivered its first set of
recommendations to the department in September 2004 with additional
recommendations to be provided in March 2005.

o 	The committee is also responsible for making recommendations to the
Secretary of HHS for transaction and code set standards.

Appendix I
National Health Information Technology
Strategy

                                   Background
                                  Role of the
               National Committee on Vital and Health Statistics

o 	In November 2001, NCVHS called for federal leadership to accelerate and
coordinate progress on a national health information infrastructure.7

o 	NCVHS intends to continue to address issues related to health IT and a
national health information infrastructure and provide comments and
recommendations to the Secretary as appropriate.

o 	NCVHS reviews results of HHS agencies' standards-setting initiatives,
along with government and nongovernmental requirements and issues, and
makes recommendations to the department secretary regarding the adoption
of health IT standards, as appropriate.

7 NCVHS, Information for Health: A Strategy for Building the National
Health Information Infrastructure (Washington, D.C.: November 2001).

Appendix I
National Health Information Technology
Strategy

                                   Background

                            DOD's Role in Health IT

o 	As previously reported,8 DOD has pursued the goal of providing IT
support to its hospitals and clinics since 1968.

o 	From 1976 to 1984, DOD spent about $222 million to acquire, implement,
and operate various health care computer systems.

o 	The Composite Health Care System (CHCS), deployed in 1993, is the
primary DOD medical information system now used in all military health
system facilities worldwide, supporting patient registration and inpatient
activity documentation, and providing laboratory, radiology, pharmacy,
drug interaction, and other functions.

Appendix I
National Health Information Technology
Strategy

                                   Background

                            DOD's Role in Health IT

o 	DOD initiated CHCS II in 1997 as an advanced medical information system
to assist clinicians in making improved health care decisions and to lower
costs.

o 	As part of CHCS II, DOD is implementing a centralized Clinical Data
Repository of life-long health records for military health system
beneficiaries that provide documentation such as patient histories,
physician notes, and population health reporting.

o 	CHCS II represents DOD's EHR and will eventually replace the existing
CHCS.

o 	According to HHS, DOD has a lengthy history working in remote and
medically underserved areas and has experience in using IT, such as
telehealth, to deliver care in isolated conditions which can be compared
with the conditions in some rural environments.

Appendix I
National Health Information Technology
Strategy

                                   Background

                             VA's Role in Health IT

o 	VA is the country's largest health care provider and, according to
RAND,9 has been making significant strides in implementing technologies
and systems to improve care, including an EHR that allows instant
communication among providers across the country and reminds providers of
patients' clinical needs.

o 	As we previously reported10, VA has had an automated information system
in its medical facilities since 1985. In 1996, this system evolved into
the Veterans' Health Information Systems and Technology Architecture
(VistA), an integrated outpatient and inpatient system that includes its
EHR-the Computerized Patient Record System.

o 	VA's EHR technologies are available for public use and are being
modified for transfer to rural and medically underserved settings.

9 RAND, Improving Quality of Care: How the VA Outpaces Other Systems in
Delivering Patient Care (Santa Monica, CA: 2005). 10 GAO, Information
Technology: Benefits Realized for Selected Health Care Functions,
GAO-04-224 (Washington, D.C.: October 22 31, 2003)

Appendix I
National Health Information Technology
Strategy

                                   Background

                      Private Industry's Role in Health IT

According to the National Coordinator for Health IT:

o 	While the federal government plays an important role in health IT
adoption, the effective use of health IT lies predominantly with the
private sector.

o 	The federal government can provide a vision and strategic direction for
a national interoperable health care system but will rely on the private
sector to provide a competitive technology industry, privately operated
support services, and shared investments in health IT adoption.

o 	The private sector must develop the market institutions to deliver the
products and services that can transform the paper-based health care
system into an electronic, consumer-centered, and quality-based system.

Appendix I
National Health Information Technology
Strategy

                                   Background

                              Relevant Legislation

Federal legislation requires specific activities related to the
implementation of health IT by both the public and private sectors.

o 	The Health Insurance Portability and Accountability Act (HIPAA) of
199611 requires HHS to establish national standards for certain financial
and administrative electronic health care transactions and national
identifiers for providers, health plans, and employers.

o 	The Public Health Security and Bioterrorism Preparedness and Response
Act of 200212 requires that the Secretary, in cooperation with health care
providers and state and local public health officials, establish standards
for interoperability of health alert and public health surveillance
networks between federal, state, and local public health officials, and
public and private health labs, hospitals and other facilities.

Appendix I
National Health Information Technology
Strategy

                                   Background

                              Relevant Legislation

o 	Among other things, the Medicare Prescription Drug Improvement and
Modernization Act of 200313 includes provisions for an electronic
prescription drug program and requires CMS to develop standards for
electronic prescribing.

o 	It also requires the establishment of a Commission on Systemic
Interoperability to provide a road map for interoperability standards.

o 	The act authorizes the Secretary of HHS to conduct a 3-year
pay-forperformance demonstration program under which physicians are to
adopt and use health IT to promote continuity of care, stabilize medical
conditions, prevent or minimize acute exacerbations of chronic conditions,
and reduce adverse health outcomes to meet beneficiaries' needs.

13 Public Law 108-173 (December 8, 2003).

Appendix I
National Health Information Technology
Strategy

                                   Background

                       Previous GAO Reports on Health IT

o 	GAO has historically reviewed and reported issues related to the
federal government's efforts to implement health IT, including the need
for an implementation strategy, costs and benefits of health IT, barriers
to implementation, and DOD's and VA's efforts to implement EHRs and
exchange data.

o  Appendix I includes descriptions of GAO reports issued since 2000.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                Office of the National Coordinator for Health IT

o 	The mission of the Office of the National Coordinator for Health IT is
to develop and implement a strategic plan to guide the nationwide
implementation of interoperable health care IT in both the public and
private sectors.

o 	According to the national coordinator, the office is a transitional
organization with no permanent positions under the HHS Assistant Secretary
for Budget, Technology and Finance.

o 	The first step in preparing a strategic plan was the release of a
framework for strategic action, and in accordance with Executive Order
13335, HHS released The Decade of Health Information Technology:
Delivering Consumer-centric and Information-rich Health Care (July 2004),
which describes a framework for strategic action.

o 	The office intends to release a complete strategic plan during this
coming year to build upon the framework and provide detailed plans for
implementing the President's vision.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

Framework for Strategic Action

o 	The framework for strategic action outlines an approach toward the
nationwide implementation of interoperable health IT in both the public
and the private sectors.

o 	It calls for a sustained set of actions which will be taken over many
years by the public and private health sectors.

o 	The framework outlines four major goals and 12 strategies for
implementing a strategy for national health IT.

o 	The framework states a commitment to the development of
interoperability standards, a key component of progress in interoperable
health IT, and describes efforts to adopt standards for use by all federal
health agencies.

o 	The framework also supports the role of the private sector and
recognizes that the adoption and effective use of health IT require a
joint effort between federal, state, and local governments and the private
sector.

o 	As we testified in July 2004, as the national coordinator moves forward
with this framework, it will be essential to have continued leadership,
clear direction, measurable goals, and mechanisms to monitor progress.14

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                         Framework for Strategic Action

o 	HHS's approach for implementing the framework's strategic actions
aggregates its goals and strategies into three phases.

o 	Phase I focuses on the development of market institutions to stabilize
the market, create a better environment for investment and accountability,
and lower the risk of health IT procurement.

o 	Phase II involves investment in clinical management tools and
capabilities such as EHRs, personal health records, telehealth, health
information exchange, and other mechanisms for high-performance care
delivery.

o 	Phase III supports the transition of the market to robust quality and
performance accountability, where clinicians have the tools and
capabilities to manage patients and populations and to deliver
consistently high-quality care in an efficient manner.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                         Framework for Strategic Action

o 	HHS is currently implementing phase I and, according to the national
coordinator, its initial efforts are focused on the building blocks of EHR
adoption, interoperability, and streamlined federal health information
systems.

o 	These building blocks are necessary to enable both the private and
public sectors to implement interoperable health information systems and
to provide a foundation for efforts in later phases, such as personal
health records and biosurveillance.

o 	However, HHS has not established milestones for the completion of phase
I, nor has it defined or made plans for phases II and III.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                         Framework for Strategic Action

o 	According to officials with the Office of the National Coordinator for
Health IT, the office is in the process of establishing milestones for the
completion of phase I but has not made plans for phases II and III because
HHS has not formalized the organization or funding for future activities.

o 	Without defined milestones it remains unclear when the important
activities of phase I will be completed and when the building blocks to
support activities of the subsequent phases will be available.

o 	The following slides describe the framework's 4 goals and 12 strategies
and key HHS IT initiatives that support the phase I goals.

Appendix I
National Health Information Technology
Strategy

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                          Phase I: Standards for EHRs

o 	HHS is working with the private sector to develop standards for EHR
functionality, interoperability, and security in order to reduce the risk
of EHR implementation failure, a goal 1 strategy.

o 	In July 2004, three leading health care industry associations-the
Health Information and Management Systems Society, American Health
Information Management Association, and National Alliance for Health
IT-established a private sector task force to develop certification
requirements for ambulatory EHRs.

o 	The Certification Commission for Health IT is made up of private sector
and not-for-profit members with federal employees serving as experts on
the commission's work groups.

o 	The committee plans to define a basic certification process for EHRs in
ambulatory settings by summer 2005.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

Phase I: HHS Support for Regional Collaborations  o  Currently, there are
two HHS programs to support regional collaborations through grants and
contracts.

o 	In October 2004, AHRQ announced $139 million in multi-year grants and
contracts to promote the use of health IT, including five-year contracts
to five states to help them develop statewide networks.

o 	HRSA's Office for the Advancement of Telehealth provides seed money and
support to multi-stakeholder collaboratives within communities to
implement regional health information organizations. It provided $2.3
million in 2004.

o 	These programs support the goal 2 strategy to foster regional
collaborations.

o 	The Office of the National Coordinator for Health IT plans to host an
interoperability meeting with stakeholders this year to address
requirements for regional organizations and the national health
information network.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy
                  Phase I: National Health Information Network

o 	In November 2004, HHS issued a request for information (RFI) for ideas
to develop a national health information network (NHIN)15-a goal 2
strategy.

o 	The network is intended to provide technologies for the secure movement
of information used in the delivery of health care in the U.S integrated
with public health surveillance and response, and shared within the public
domain.

o 	If implemented properly, the network should help achieve
interoperability of health IT used in the mainstream delivery of health
care in America, particularly pertaining to the information contained in
or used by EHRs.

o 	A key component of a NHIN is the development of interoperability
standards and policies for diffusion into practice.

o 	The RFI addresses the goal to interconnect clinicians by seeking public
comment and input regarding how widespread interoperability of health IT
and health information exchange can be achieved.

15 The national health information network is now referred to as the
nationwide health information network.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

Phase I: National Health Information Network

o 	The results of the RFI are intended to provide information for policy
discussions inside and outside the government about possible methods by
which widespread interoperability and health information exchange could be
deployed and operated on a sustainable basis.

o 	HHS intends to explore the role of the federal government in
facilitating deployment of a national health information network, how it
could be coordinated with efforts to define a federal health architecture,
and how it could be supported and coordinated by regional health
information organizations.16

o 	The RFI also requests input regarding privacy and security
considerations, including compliance with HIPAA rules and the role of the
private sector in the construction and implementation of a NHIN.

o 	According to the national coordinator, HHS received over 500 responses
and has convened a governmentwide task force made up of over 100 people
from 17 agencies to review the responses and produce a summary.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

Phase I: Federal Health Information Systems

o 	The office of the national coordinator is responsible for the Federal
Health Architecture (FHA) program which is to define a framework and
methodology for establishing the target architecture and standards for
interoperability and communication throughout the federal health
community, supporting a goal 2 strategy to coordinate federal health
information systems

o 	FHA was initiated in 2003 in HHS's office of the chief information
officer and was incorporated into the national coordinator's office in
2004.

o 	FHA is intended to provide a structure for bringing HHS's divisions and
other federal departments together through its partners' council,17
initially targeting standards for enabling interoperability.

o  The FHA program is supported by four advisory work groups.

o 	Appendix II includes descriptions of the FHA work groups and their
responsibilities, followed by a table describing membership.

17 The FHA partners' council includes almost 400 members from 15 agencies

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                  Phase I: Federal Health Information Systems

o 	The FHA partners are responsible for improving coordination and
collaboration on federal health IT solutions and investments and improving
efficiency, standardization, reliability, and availability of health
comprehensive information solutions.

o 	According to the national coordinator, there is a strong need for the
federal government's health information systems to be able to exchange
data so that these systems become more efficient and costeffective.

o 	HHS plans to produce in September 2005 the first release of an
information architecture for the federal health enterprise to enable
collaboration and data sharing across the government and with various
organizations, such as states and private entities.

o 	The first release will contain foundational elements to support the
development and evolution of the full architecture which will occur over
several years.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                  Phase I: Federal Health Information Systems

o 	The FHA's Consolidated Health Informatics (CHI) initiative is focused
on the adoption of health information interoperability standards,
identification of gaps and additional work areas in domains without
standards recommendations, and coordination with developers of health
information interoperability standards to promote accessibility and
distribution of adopted standards to support the FHA.

o 	Consolidated Health Informatics was initiated in December 2001 as an
OMB e-government project to establish federal health information standards
to enable federal agencies to build interoperable health data systems.

o  The project was incorporated into FHA in September 2004.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                        Phase I: Personal Health Records

o 	In January 2005, NCVHS held hearings on personal health records-a goal
3 strategy to personalize care-and identified issues, some specifically
related to the federal government.

o 	Issues discussed include privacy and information control, security of
health information, legal issues, cost, and interoperability.

o 	Federal issues include the relationship of roles in and uses of
personal health records to the larger health objectives of the federal
government, such as (1) what costs agencies will face, (2) how the federal
government should promote interoperability, and (3) whether there needs to
be a standardized approach to a personal health record across all of the
federal activities.

o 	The hearings also discussed broader issues such as ownership and
control of personal health information and policy issues such as access
rights and authorization of usage.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy
               Framework Support: Standards and Interoperability

o 	According to the national coordinator, the development of technically
sound and robustly specified interoperability standards and policies is a
key component of progress toward the implementation of a national strategy
that provides interoperable health IT systems

o 	The development, approval, and adoption of standards for health IT is
an ongoing, long-term process that supports multiple goals of the
framework and includes federally mandated standards requirements (e.g.,
HIPAA) and a voluntary consensus process within a market-based health care
industry.

o 	The use of some standards, such as those defined by HIPAA and MMA, is
mandated by the federal government while others are defined by standards
development organizations such as the American Association of Medical
Instrumentation and the National Council for Prescription Drug Programs.

o 	The following graphic provides an overview of the highly complex
standards-setting process for health care data exchange in the United
States.

Appendix I
National Health Information Technology
Strategy

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

               Framework Support: Standards and Interoperability

o 	HHS identifies and researches standards that are defined by standards
development organizations and determines which approved standards are
appropriate for use in federal agencies' health IT systems.

o 	According to an HHS official, the department has limited authority to
mandate standards outside of the federal government, but, through the
Consolidated Health Informatics initiative, is encouraging the
implementation of standards within the federal government to provide a
catalyst for the private sector to follow.

o 	Federal agencies agreed to endorse 20 domains of health data standards
for information exchange as a model for the private sector, yielding 11
sets of standards to be used in federal IT architectures.

o 	HHS is committed to supporting collaboration between the public and
private sectors to develop, adopt, and certify standards.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

               Framework Support: Standards and Interoperability

o 	HHS divisions, such as AHRQ, CMS, NIH, CDC, and FDA, have been and
continue to be responsible for selecting and adopting standards and are
now included in the CHI initiative, supporting multiple goals of the
framework.

o 	AHRQ and CMS are working on initiatives that support goal 1 of the
framework.

o 	AHRQ is working to identify and establish clinical standards and
research to help accelerate the adoption of interoperable health IT
systems, including

o  industry clinical messaging and terminology standards,

o  national standard nomenclature for drugs and biological products, and

o  standards related to clinical terminology.

o 	CMS is responsible for identifying and adopting standards for
e-prescribing and for implementing the administrative simplification
provisions of HIPAA, including electronic transactions and code sets,
security, and identifiers.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

Framework Support: Standards and Interoperability

o  NIH's work on standards supports the framework's goal 2.

o 	NIH's National Library of Medicine (NLM) is working on the
implementation of standard clinical vocabularies, including support for
and development of selected standard clinical vocabularies to enable
ongoing maintenance and free use within the United States' health
communities, both private and public.

o 	In 2003, NLM obtained a perpetual license for the Systematized
Nomenclature of Medicine (SNOMED)18 standard and ongoing updates, making
SNOMED available to U.S. users.

o 	Other efforts at NLM include the uniform distribution and mapping of
HIPAA code sets, standard vocabularies, and Health Level 719 code sets.

18 SNOMED is a nomenclature classification for indexing medical
vocabulary, including signs, symptoms, diagnoses, and procedures. It was
adopted as a CHI standard in May 2004. 45

19 HL7 is a standards development organization that creates message format
standards for electronic exchange of health information.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

               Framework Support: Standards and Interoperability

o 	The Centers for Disease Control and Prevention (CDC), FDA, and NIH are
working on standards-setting initiatives that support the framework's goal
4.

o 	CDC, through its Public Health Information Network (PHIN) initiative,
is working on the development of shared data models, data standards, and
controlled vocabularies for electronic laboratory reporting and public
health information exchange that are compatible with federal standards
activities such as CHI.

o 	FDA and NIH, together with the Clinical Data Interchange Standards
Consortium, a group of over 40 pharmaceutical companies and clinical
research organizations, have developed a standard for representing
observations made in clinical trials, the Study Data Tabulation Model.

o 	In May 2003, we recommended to HHS that ongoing standards-setting
organizations coordinate their efforts to define and implement health IT
standards (GAO-03-139; see appendix I).

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

Framework's Goals and Supporting HHS IT Initiatives  o  In addition to
those already described, other ongoing HHS IT initiatives support the
framework's goals.

o 	The following table lists key HHS IT initiatives for health IT by
division and identifies the goals that they support.

o  Descriptions of each of the initiatives are included in appendix III.

Appendix I
National Health Information Technology
Strategy

Appendix I
National Health Information Technology
Strategy

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                Framework Support: Private Sector Participation

o 	Certain private sector activities provide support for goals 1 and 2 of
the framework.

o 	The private sector task force, the Certification Commission for Health
IT, is working to develop certification procedures for EHRs, supporting
goal 1.

o 	The Commission on Systemic Interoperability, which includes nationally
recognized experts in the area of health IT, is charged by the Medicare
Modernization Act to develop a comprehensive strategy for the adoption and
implementation of health care IT interoperability standards, which
supports goal 2.

Appendix I
National Health Information Technology
Strategy

                          National Health IT Strategy

                Framework Support: Private Sector Participation

o 	HHS has supported and continues to support opportunities for private
sector participation in establishing health care IT through grants and
funding for demonstration projects through its divisions.

o 	HHS participates with the medical and public health communities,
academia, and health IT vendors through conferences and symposia.

o 	The national coordinator speaks at industry conferences that are
focused on identifying government incentives to encourage health IT
adoption in private industry.

o 	HHS's Secretarial Summit on Health IT held in July 2004 provided
nongovernmental participants opportunities to make recommendations
regarding incentives for health IT, population health, clinical research,
and health IT governance.

o 	According to HHS, close collaboration between public and private
sectors can develop new methods for improving care without creating
unnecessary regulation and minimizing reporting burdens on private
industry.

Appendix I
National Health Information Technology
Strategy

                        Lessons Learned from VA and DOD

o 	DOD and VA experiences in implementing EHRs offer important lessons
learned that could be used in developing and implementing a national
health care effort. As providers and payers of health care services, DOD
and VA's lessons include

o  Obtain full endorsement of top leadership

o 	Senior administrators and clinical leaders should share and communicate
a common sense of urgency regarding the need for change.

o 	Senior leadership's full endorsement, including support for funding, is
critical to successfully implementing an electronic health record,
promoting end-user support, and securing a usable product.

Appendix I
National Health Information Technology
Strategy

                        Lessons Learned from VA and DOD

o  Implement an enterprise-wide communication plan

o 	EHR implementation entails organizational change and acceptance across
the enterprise and at all organizational levels.

o 	System acceptance and support depend upon regular, effective
communication, from executive leadership levels down through end users.

o 	Keeping stakeholders informed of objectives, progress, problems
encountered and resolved, lessons learned, and benefits is critical to
setting realistic expectations and facilitating stakeholder buy-in.

Appendix I
National Health Information Technology
Strategy

                        Lessons Learned from VA and DOD

o  Recognize and address needs of the varied stakeholder communities

o 	A management/governance structure that represents the entire
stakeholder community should be established, and reflect clearly defined
roles, responsibilities, and decision-making authority among the different
levels of leadership.

o 	Users (i.e., clinicians, payers, and others) should have an early and
integral role in defining a strategy to meet their needs, establish
accountability for the initiative, and sustain long-term project success.

o 	Users should be actively involved in all project phases, including
requirements definition, system design, development, testing, and
implementation.

                                       54

Appendix I
National Health Information Technology
Strategy

                        Lessons Learned from VA and DOD

o 	Define and adopt common standards, terminology, and performance
measures

o 	Early definition and adoption of common standards, terminology, and
performance measures (communication, data, and security) and agreement on
related implementation guidelines are essential to achieving data quality
and consistency, system interoperability, and information protection.

o  Deploy in small increments and build on success

o 	Follow an incremental system development approach to accommodate
evolving business processes, requirements, and technology changes; limit
initial deployment to a few test sites to allow time for the process to
mature, and assimilate lessons learned before full deployment.

Appendix I
National Health Information Technology
Strategy

                        Lessons Learned from VA and DOD

o  Customize training and support to sustain system implementation

o 	Establish training programs that are tailored to meet the needs of the
varied users' groups. On-site clinical champions and subjectmatter experts
should be identified and empowered to promote and demonstrate the new
system to other personnel and provide ongoing technical assistance.

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

                        Canada, Denmark, and New Zealand

o 	While the U.S. has just begun to develop a national strategy for health
IT adoption, Canada and Denmark have developed national strategies and
begun to take steps toward implementation, and New Zealand plans to
finalize its strategy in June 2005.

o  Canada finalized its strategy in 2004 and is a year into
implementation.

o 	Denmark finalized its strategy in February 2003 and is 2 years into a
4-year implementation plan.

o 	New Zealand has prioritized six initiatives to be implemented in the
next 3 to 5 years.

o 	These countries are farther along in their strategy development and
implementation than the U.S. and are able to share lessons learned from
their experiences.

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

                    Overview of Canada's Health Care System

o 	The Canadian health care system supports publicly financed health for
over 31 million people.

o 	The federal government is responsible for direct health service
delivery to veterans, native Canadians living on reserves, military
personnel, inmates of federal penitentiaries, and the Royal Canadian
Mounted Police, as well as health protection, disease prevention, and
health promotion services.

o 	The administration and delivery of health care services is the
responsibility of each province or territory, guided by the provisions of
the Canada Health Act. The provinces and territories fund these services
with assistance from the federal government in the form of fiscal
transfers.

o 	Canada Health InfoWay is working with the provinces and territories to
advance the IT building blocks needed for the health care system.

o 	Canada Health InfoWay is a corporation whose board of directors is made
up of representatives from all of the provinces and territories, as well
as elected representatives.

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

                          Lessons Learned from Canada

Lessons Learned

o  Focus on creating standards first.

o 	Recognize that creating a health IT infrastructure takes years, and
benefits may not be realized in the short term.

o 	Identify a central visible point to provide political advocacy and
highlight the achievements of health IT as work progresses to help
maintain support for long-term projects.

o 	Identify and provide appropriate incentives based on provincial and
territorial elements to motivate physicians to use IT.

o  Proactively resolve issues related to privacy protection.

o 	Anticipate and mitigate border-crossing issues with implementing
telehealth, such as issues with licensing arrangements and cross-border
reimbursements.

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

                    Overview of Denmark's Health Care System

o 	The Danish health care system serves a population of 5.3 million people
and is 85% tax-financed.

o 	At the national level, the Ministry of Health is responsible for
legislation and preparing overall guidelines for the health care sector,
and the National Board of Health is responsible for supervising health
personnel.

o 	The regional level consists of 14 counties and the Copenhagen Hospital
Corporation. The counties own and run hospitals and prenatal care centers
and finance general and specialist practitioners, pharmacies and
physiotherapists through the National Health Security System.

o 	The responsibility for the municipal level includes nursing homes, home
nursing, health visitors, and school health services.

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

                    Overview of Denmark's Health Care System

o 	Denmark's National Strategy for IT in Health Care 2003 -2007 was
finalized in February 2003.

o 	It states that the most important reasons for increasing the use of IT
in health care are related to the improvement of quality, efficiency, and
effectiveness of health care delivery.

o  Three major initiatives of the National Strategy are

o  coordinated development, testing, and implementation of EHRs,

o 	a national database to organize health care terms and concepts, and

o 	concept classifications to facilitate communications across sectors and
professions in health care.

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

                          Lessons Learned from Denmark

Lessons Learned

o  Implementation of health IT across the entire country will take a long
time.

o 	Involve health care service providers throughout the entire
implementation process.

o 	A very strong central organization must lead the entire health IT
implementation from start to finish.

o 	Integrate federal efforts with hospitals before undertaking a larger
national plan.

o 	Anticipate and resolve funding, IT process reengineering,
consensusbuilding, and other issues during the planning phase to avoid
negative impacts on progress.

o 	Realize that the investment in health care IT is costly, and short-term
gains are hard to identify.

o 	Promote successes as soon as possible to encourage acceptance by
stakeholders.

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

                  Overview of New Zealand's Health Care System

o 	The New Zealand health care system serves a population of 4 million
people.

o 	At the national level, the Ministry of Health provides policy advice on
improving health outcomes and monitors the performance of the district
health boards.

o 	The regional level consists of 21 district health boards. Each district
health board has up to 11 members, seven of which are elected by the
community and up to four of which are appointed by the Minister of Health.

o 	District health boards are responsible for planning, funding and
ensuring the provision of health and disability services to a
geographically defined population.

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

                  Overview of New Zealand's Health Care System

o 	New Zealand is currently redeveloping its health information strategy,
which is expected to be complete by June 2005.

o 	The draft strategy identifies 12 action zones for implementation
planning over the next 3 to 5 years; six were selected as initial
priorities:

o  Enable secure connections and access to health information

o 	Ensure national systems anchors (such as the National Health Index) are
in place

o  Create and publish accessible key event summaries

o 	Expand the level of electronic communication across primary and
secondary care

o  Extend the collection of health information

o 	Safe Access to National Information within the context of the Health
Information Privacy Code is essential for the support of population health

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

                        Lessons Learned from New Zealand

Lessons Learned

o 	The distributed government model that governs New Zealand's health care
system works best.

o 	High level EHR components that can be shared and accessed encourage
greater coordination of health services.

o  Provide adequate funding for and prioritize the initiatives

o 	Educate stakeholders about the value of developing health IT to
encourage stakeholder buy-in.

Appendix I
National Health Information Technology
Strategy

                      Lessons Learned from Other Countries

              Overview of the United Kingdom's Health Care System

o 	The United Kingdom's Department of Health is responsible for setting
health and social care policy in England; health services are largely
taxfinanced in the United Kingdom and account for 14 per cent of general
government spending.

o 	In summer 2002, the government set up the National Programme for IT
(NPfIT) which defines four main projects to be introduced in stages across
different regions:

o  Electronic Patient Records

o  Electronic Appointment Booking

o  Electronic Transmission of Prescriptions

o  Communications Network

o 	NPfIT plans to have electronic booking substantially in place and to
have 50% of prescriptions transmitted electronically by the end of 2005.

o 	We could not identify lessons learned from the United Kingdom's efforts
based upon publicly available information.

Appendix I
National Health Information Technology
Strategy

                                  Conclusions

o 	Since establishing the Office of the National Coordinator for Health
IT, HHS has made progress toward coordinating federal health IT efforts
and reaching out to private industry.

o 	However, coordination of standards development and adoption activities
throughout the health care industry, including federal efforts to
accelerate the process, remains a challenge.

o 	HHS has not made long-term plans or established milestones for the
implementation of a national strategy to accelerate the adoption of IT
across the health care industry.

Appendix I
National Health Information Technology
Strategy

                                  Conclusions

o 	DOD's and VA's experiences in implementing EHR systems offer important
lessons learned that may be applied to HHS's efforts to help increase the
likelihood that interoperable EHRs could be available in the next ten
years.

o 	The United States could benefit from other countries' experiences and
lessons learned from their efforts toward modernizing their health IT
infrastructures.

o 	The National Coordinator for Health IT recognizes DOD's and VA's
efforts and works closely with them to share lessons learned from their
experiences with implementing health IT.

o 	The national coordinator has recently initiated discussions with other
countries to also learn from their experiences in modernizing health
information infrastructures.

Appendix I
National Health Information Technology
Strategy

                                 Recommendation

To accelerate the adoption of interoperable IT for health care, we
recommend that the Secretary of HHS

o 	establish detailed plans and milestones for each phase of the framework
for strategic action, and

o  take steps to ensure that plans are followed and milestones are met.

Appendix I
National Health Information Technology
Strategy

                                Agency Comments

We requested comments from HHS, DOD, and VA on a draft of these briefing
slides.

o  HHS did not provide comments.

o 	DOD's Chief Enterprise Architect for Military Health System provided
written technical comments, which we incorporated as appropriate.

o 	VA's Acting Deputy Chief Information Officer for Health provided oral
comments and agreed with the information presented.

Appendix I
National Health Information Technology
Strategy

                                   Appendix I

                        Recent GAO Reports on Health IT

o 	Health and Human Services' Estimate of Health Care Cost Savings
Resulting from the Use of Information Technology (GAO-05-309R; February
17, 2005): We reported that IT can improve the efficiency and quality of
medical care and result in costs savings and that, although estimated
nationwide savings are primarily based on studies with methodological
limitations and are contingent on much higher IT adoption rates than are
currently estimated, the potential for substantial savings is promising.

o 	Health Care: HHS's Efforts to Promote Health Information Technology and
Legal Barriers to its Adoption (GAO-04-991R; August 13, 2004): We
identified major HHS IT initiatives and associated funding, and reported
that attempts by the federal government to address legal issues that
present barriers to the widespread use of IT have not been sufficient.

o 	Health Care: National Strategy Needed to Accelerate the Implementation
of Information Technology, (GAO-04-947T; July 14, 2004): We reported that
it will be essential to have continued leadership, clear direction,
measurable goals, and mechanisms to monitor progress of the implementation
of a national strategy for health IT.

o 	Computer-Based Patient Records: VA and DOD Efforts to Exchange Health
Data Could Benefit from Improved Planning and Project Management,
(GAO-04-687; June 7, 2004): To help ensure progress in achieving the
two-way exchange of health information, we recommended that VA and DOD
develop an architecture for an electronic interface between their health
systems and establish a project management structure to guide the
initiative.

Appendix I
National Health Information Technology
Strategy

                                   Appendix I

                        Recent GAO Reports on Health IT

o 	Computer-Based Patient Records: Improved Planning and Project
Management Are Critical to Achieving Two-Way VA-DOD Health Data Exchange,
(GAO-04-811T; May 19, 2004): We testified that DOD and VA were continuing
with activities to support the sharing of health data; nonetheless,
achieving the two-way electronic exchange of patient health information
remained far from being realized.

o 	Computer-Based Patient Records: Sound Planning and Project Management
Are Needed to Achieve A Two-Way Exchange of VA and DOD Health Data
(GAO-04-402T; March 17, 2004): We testified that DOD and VA had made
little progress since November 2003 in determining an approach for
achieving two-way exchange of patient data and reported that DOD and VA
have taken measures towards implementing prior recommendations for
enhancing management and accountability.

o 	Computer-Based Patient Records: Short-Term Progress Made But Much Work
Remains to Achieve A Two-Way Data Exchange Between VA and DOD Health
Systems (GAO-04-271T; November 19, 2003): We testified that DOD and VA
faced challenges in exchanging standardized data and that a common health
information infrastructure and architecture was needed to achieve data
exchange capability.

Appendix I
National Health Information Technology
Strategy

                                   Appendix I

                        Recent GAO Reports on Health IT

o 	Information Technology: Benefits Realized for Selected Health Care
Functions ( GAO-04224, October 31, 2003): We reported significant
improvements in health care delivery and financial benefits realized from
the nation's health care community's implementation of health IT,
including cost savings resulting from VA's and DOD's implementation of
health IT.

o 	Bioterrorism: Information Technology Strategy Could Strengthen Federal
Agencies' Abilities to Respond to Public Health Emergencies (GAO-03-139;
May 30, 2003): We recommended that HHS coordinate with DHS, DOD, and VA to
establish a national IT strategy, and that ongoing standards-setting
organizations coordinate their efforts to define and implement health IT
standards.

o 	Computer Based Patient Records: Better Planning and Oversight by VA,
DOD, and IHS Would Enhance Health Data Sharing (GAO-01-459; April 30,
2001): We recommended that DOD, VA, and IHS create comprehensive and
coordinated plans to ensure that the agencies can share patient health
data, including performance measures and use of existing IT capabilities.

Appendix I
National Health Information Technology
Strategy

                                  Appendix II

                      Responsibilities of FHA Work Groups

o 	Food safety: recommend a target, business architecture to serve as the
framework for developing and implementing systems which support the food
safety business government-wide

o 	Interoperability: recommend target technical standards for
interoperability across the health line of business.

o 	EHR: recommend a target, health care services electronic health record
business architecture, a component of the health lines of business, to
serve as framework within the federal sector for developing and
implementing an electronic health record.

o 	Public health surveillance: recommend a target architecture related to
the health line of business to serve as the framework within the federal
sector for developing and implementing public health surveillance systems.

Appendix I
National Health Information Technology
Strategy

Appendix I
National Health Information Technology
Strategy

Appendix I
National Health Information Technology
Strategy

Appendix I
National Health Information Technology
Strategy

Appendix II

Comments from the Department of Health and Human Services

Appendix II
Comments from the Department of Health
and Human Services

                                       M

Appendix II
Comments from the Department of Health
and Human Services

Appendix II
Comments from the Department of Health
and Human Services

Appendix III

Comments from the Department of Veterans Affairs

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