Health IT Strategic Framework
Executive Summary
On April 27, 2004, President Bush called for widespread adoption of
interoperable EHRs within 10 years, and also established the position of
National Coordinator for Health Information Technology. On May 6, 2004,
Secretary Tommy G. Thompson appointed David J. Brailer, M.D., Ph.D., to serve
in this new position. The federal government has already played an
active role in the evolution and use of health information technology (HIT),
including adoption and ongoing support for standards needed to achieve
interoperability. Executive Order 13335 requires the National
Coordinator to report within 90 days of operation on the development and
implementation of a strategic plan to guide the nationwide implementation of
HIT in both the public and private sectors.
In fulfilling the requirements of the Executive Order, this report
outlines a framework for a strategic plan that will be dynamic, iterative,
and implemented in coordination with the private sector. In addition,
this report includes attachments from the Office of Personnel Management
(OPM), the Department of Defense (DoD), and the Department of Veterans
Affairs (VA). Collectively, this report and related attachments
represent the progress to date on the development and implementation of a
comprehensive HIT strategic plan.
Readiness for Change
There is a great need for information tools to be used in the delivery of
health care. Preventable medical errors and treatment variations have
recently gained attention. Clinicians may not know the latest treatment
options, and practices vary across clinicians and regions. Consumers
want to ensure that they have choices in treatment, and when they do, they
want to have the information they need to make decisions about their
care. Concerns about the privacy and security of personal medical
information remain high. Public health monitoring, bioterror
surveillance, research, and quality monitoring require data that depends on
the widespread adoption of HIT.
Vision for Consumer-centric and Information-rich Care
Many envision a health care industry that is consumer centric and
information-rich, in which medical information follows the consumer, and
information tools guide medical decisions. Clinicians have appropriate
access to a patient's complete treatment history, including medical records,
medication history, laboratory results, and radiographs, among other
information. Clinicians order medications with computerized systems
that eliminate handwriting errors and automatically check for doses that are
too high or too low, for harmful interactions with other drugs, and for
allergies. Prescriptions are also checked against the health plan's
formulary, and the out-of-pocket costs of the prescribed drug can be compared
with alternative treatments. Clinicians receive electronic reminders in
the form of alerts about treatment procedures and medical guidelines.
This is a different way of delivering health care than that which currently
exists, but one that many have envisioned. This new way will result in
fewer medical errors, fewer unnecessary treatments or wasteful care, and
fewer variations in care, and will ultimately improve care for all
Americans. Care will be centered around the consumer and will be
delivered electronically as well as in person. Clinicians can spend
more time on patient care, and employers will gain productivity and
competitive benefits from health care spending.
Strategic Framework
In order to realize a new vision for health care made possible through the
use of information technology, strategic actions embraced by the public and
private health sectors need to be taken over many years. There are four
major goals that will be pursued in realizing this vision for improved health
care. Each of these goals has a corresponding set of strategies and
related specific actions that will advance and focus future efforts.
These goals and strategies are summarized below.
Goal 1: Inform Clinical Practice. Informing clinical
practice is fundamental to improving care and making health care delivery
more efficient. This goal centers largely around efforts to bring EHRs
directly into clinical practice. This will reduce medical errors and
duplicative work, and enable clinicians to focus their efforts more directly on
improved patient care. Three strategies for realizing this goal are:
- Strategy 1.
Incentivize EHR adoption. The transition to safe, more
consumer-friendly and regionally integrated care delivery will require
shared investments in information tools and changes to current clinical
practice.
- Strategy 2.
Reduce risk of EHR investment. Clinicians who purchase EHRs
and who attempt to change their clinical practices and office operations
face a variety of risks that make this decision unduly
challenging. Low-cost support systems that reduce risk, failure,
and partial use of EHRs are needed.
- Strategy 3.
Promote EHR diffusion in rural and underserved areas.
Practices and hospitals in rural and other underserved areas lag in EHR
adoption. Technology transfer and other support efforts are needed
to ensure widespread adoption.
Goal 2: Interconnect Clinicians. Interconnecting
clinicians will allow information to be portable and to move with consumers
from one point of care to another. This will require an interoperable
infrastructure to help clinicians get access to critical health care
information when their clinical and/or treatment decisions are being
made. The three strategies for realizing this goal are:
- Strategy 1.
Foster regional collaborations. Local oversight of health
information exchange that reflects the needs and goals of a population
should be developed.
- Strategy 2.
Develop a national health information network. A set of common
intercommunication tools such as mobile authentication, Web services
architecture, and security technologies are needed to support data
movement that is inexpensive and secure. A national health
information network that can provide low-cost and secure data movement
is needed, along with a public-private oversight or management function
to ensure adherence to public policy objectives.
- Strategy 3.
Coordinate federal health information systems. There is a need
for federal health information systems to be interoperable and to
exchange data so that federal care delivery, reimbursement, and
oversight are more efficient and cost-effective. Federal health
information systems will be interoperable and consistent with the
national health information network.
Goal 3: Personalize Care. Consumer-centric information
helps individuals manage their own wellness and assists with their personal
health care decisions. The ability to personalize care is a critical
component of using health care information in a meaningful manner. The
three strategies for realizing this goal are:
- Strategy 1.
Encourage use of Personal Health Records. Consumers are
increasingly seeking information about their care as a means of getting
better control over their health care experience, and PHRs that provide
customized facts and guidance to them are needed.
- Strategy 2.
Enhance informed consumer choice. Consumers should have the
ability to select clinicians and institutions based on what they value
and the information to guide their choice, including but not limited to,
the quality of care providers deliver.
- Strategy 3.
Promote use of telehealth systems. The use of telehealth -
remote communication technologies - can provide access to health
services for consumers and clinicians in rural and underserved
areas. Telehealth systems that can support the delivery of health
care services when the participants are in different locations are
needed.
Goal 4: Improve Population Health. Population health
improvement requires the collection of timely, accurate, and detailed
clinical information to allow for the evaluation of health care delivery and
the reporting of critical findings to public health officials, clinical
trials and other research, and feedback to clinicians. Three strategies
for realizing this goal are:
- Strategy 1.
Unify public health surveillance architectures. An
interoperable public health surveillance system is needed that will
allow exchange of information, consistent with current law, between
provider organizations, organizations they contract with, and state and
federal agencies.
- Strategy 2.
Streamline quality and health status monitoring. Many
different state and local organizations collect subsets of data for
specific purposes and use it in different ways. A streamlined
quality-monitoring infrastructure that will allow for a complete look at
quality and other issues in real-time and at the point of care is
needed.
- Strategy 3.
Accelerate research and dissemination of evidence. Information
tools are needed that can accelerate scientific discoveries and their
translation into clinically useful products, applications, and
knowledge.
Key Actions
The Framework for Strategic Action will guide the development of a full
strategic plan for widespread HIT adoption. At the same time, a variety
of key actions that have begun to implement this strategy are underway,
including:
Establishing a Health Information Technology Leadership Panel to
evaluate the urgency of investments and recommend immediate actions
As many different options and policies are considered for financing HIT
adoption, the Secretary of HHS is taking immediate action by forming a Health
Information Technology Leadership Panel, consisting of executives and
leaders. This panel will assess the costs and benefits of HIT to
industry and society, and evaluate the urgency of investments in these
tools. These leaders will discuss the immediate steps for both the
public and private sector to take with regard to HIT adoption, based on their
individual business experience. The Health Information Technology
Leadership Panel will deliver a synthesized report comprised of these options
to the Secretary no later than Fall 2004.
Private sector certification of health information technology products
EHRs and even specific components such as decision support software are
unique among clinical tools in that they do not need to meet minimal
standards to be used to deliver care. To increase uptake of EHRs and
reduce the risk of product implementation failure, the federal government is
exploring ways to work with the private sector to develop minimal product
standards for EHR functionality, interoperability, and security. A
private sector ambulatory EHR certification task force is determining the
feasibility of certification of EHR products based on functionality,
security, and interoperability.
Funding community health information exchange demonstrations
A health information exchange program through Health Resources and Services
Administration, Office of the Advancement of Telehealth (HRSA/OAT) has a
cooperative agreement with the Foundation for eHealth Initiative to
administer contracts to support the Connecting Communities for Better Health
(CCBH) Program totaling $2.3 million. This program is providing seed
funds and support to multi-stakeholder collaboratives within communities (both
geographic and non-geographic) to implement health information exchanges,
including the formation of regional health information organizations (RHIOs)
to drive improvements in health care quality, safety, and efficiency.
The specific communities that will receive the funding through this program
will be announced and recognized during the Secretarial Summit on July 21.
Planning the formation of a private interoperability consortium
To begin the process of movement toward a national health information
network, HHS is releasing a request for information (RFI) in the summer of
2004 inviting responses describing the requirements for private sector
consortia that would form to plan, develop, and operate a health information
network. Members of the consortium would agree to participate in the
governance structure and activities and finance the consortium in an
equitable manner. The role that HHS could play in facilitating the work
of the consortium and assisting in identifying the services that the
consortium would provide will be explored, including the standards to which
the health information network would adhere to in order to ensure that public
policy goals are executed and that rapid adoption of interoperable EHRs is
advanced. The Federal Health Architecture (FHA) will be coordinated and
interoperable with the national health information network.
Requiring standards to facilitate electronic prescribing
CMS will be proposing a regulation that will require the first set of widely
adopted e-prescribing standards in preparation for the implementation of the
new Medicare drug benefit in 2006. When this regulation is final,
Medicare Prescription Drug Plan (PDP) Sponsors will be required to offer
e-prescribing, which will significantly drive adoption across the United States.
Health plans and pharmacy benefit managers that are PDP sponsors could work
with RHIOs, including physician offices, to implement private
industry-certified interoperable e-prescribing tools and to train and support
clinicians.
Establishing a Medicare beneficiary portal
An immediate step in improving consumer access to personal and customized
health information is CMS' Medicare Beneficiary Portal, which provides secure
health information via the Internet. This portal will be hosted by a
private company under contract with CMS, and will enable authorized Medicare
beneficiaries to have access to their information online or by calling
1-800-MEDICARE. Initially the portal will provide access to
fee-for-service claims information, which includes claims type, dates of
service, and procedures. The pilot test for the portal will be
conducted for the residents of Indiana.
In the near term, CMS plans to expand the portal to include prevention
information in the form of reminders to beneficiaries to schedule their
Medicare-covered preventive health care services. CMS also plans to
work toward providing additional electronic health information tools to
beneficiaries for their use in improving their health.
Sharing clinical research data through a secure infrastructure
FDA and NIH, together with the Clinical Data Interchange Standards Consortium
(CDISC), a consortium of over 40 pharmaceutical companies and clinical
research organizations, have developed a standard for representing
observations made in clinical trials called the Study Data Tabulation Model
(SDTM). This model will facilitate the automation of the largely
paper-based clinical research process, which will lead to greater
efficiencies in industry and government-sponsored clinical research.
The first release of the model and associated implementation guide will be
finalized prior to the July 21 Secretarial Summit and represents an important step by
government, academia, and industry in working together to accelerate research
through the use of standards and HIT.
Commitment to standards
A key component of progress in interoperable health information is the
development of technically sound and robustly specified interoperability
standards and policies. There have been considerable efforts by HHS, DoD,
and VA to adopt health information standards for use by all federal health
agencies. As part of the Consolidated Health Informatics (CHI)
initiative, the agencies have 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. Additionally, the Public Health
Information Network (PHIN) and the National Electronic Disease Surveillance
System (NEDSS), under the leadership of the Centers for Disease Control and
Prevention (CDC), have made notable progress in development of shared data
models, data standards, and controlled vocabularies for electronic laboratory
reporting and health information exchange. With HHS support, Health
Level 7 (HL7) has also created a functional model and standards for the EHR.
Public-Private Partnership
Leaders across the public and private sector recognize that the adoption
and effective use of HIT requires a joint effort between federal, state, and
local governments and the private sector. The value of HIT will be best
realized under the conditions of a competitive technology industry, privately
operated support services, choice among clinicians and provider
organizations, and payers who reward clinicians based on quality. The
Federal government has already played an active role in the evolution and use
of HIT. In FY04, total federal spending on HIT was more than $900
million. Initiatives range from supporting research in advanced HIT to
the development and use of EHR systems. Much of this work demonstrates
that HIT can be used effectively in supporting health care delivery and
improving quality and patient safety.
Role of the National Coordinator for Health Information Technology
Executive Order 13335 directed the appointment of the National Coordinator
for Health Information Technology to coordinate programs and policies
regarding HIT across the federal government. The National Coordinator
was charged with directing HIT programs within HHS and coordinating them with
those of other relevant Executive Branch agencies. In fulfillment of
this, the National Coordinator has taken responsibility for the National
Health Information Infrastructure Initiative (NHII), the FHA, and the
Consolidated Health Informatics Initiative (CHI), and is currently assessing
other health information technology programs and efforts. In addition,
the National Coordinator was charged with coordinating outreach and
consultation between the federal government and the private sector. As
part of this, the National Coordinator was directed to coordinate with the
National Committee on Vital Health Statistics (NCVHS) and other advisory
committees.
The National Coordinator will collaborate with DoD, VA, and OPM to
encourage the widespread adoption of HIT throughout the health care
system. To do this, the National Coordinator will gather and
disseminate the lessons learned from both DoD and VA in successfully
incorporating HIT into the delivery of health care, and facilitate the
development and transfer of knowledge and technology to the private
sector. OPM, as the purchaser of health care for the federal
government, has a unique role and the ability to encourage the use of EHRs
through the Federal Employees Health Benefits Program, and the National
Coordinator will assist in gaining the complementary alignment of OPM
policies with those of the private sector.
Reports from OPM, DoD, and VA
The Executive Order also directs the OPM, the DoD, and the VA to submit
reports on HIT to the President through the Secretary of Health and Human
Services. These reports are included in this report as Attachments 1
through 3.
OPM administers the Federal Employees Health Benefits Program for the
federal government and the more than eight million people it covers. As
the nation's largest purchaser of health benefits, OPM is keenly interested
in high-quality care and reasonable cost. The adoption of an interoperable
HIT infrastructure is a key to achieving both. OPM is currently
exploring a variety of options to leverage its purchasing power and alliances
to move the adoption of HIT forward. OPM will be strongly encouraging
health plans to promote the early adoption of HIT. Details on these
options can be found in OPM's report, "Federal Employees Health Benefits
Program Initiatives to Promote the Use of Health Information Technology"
(Attachment 1).
The VA, collaboratively with DoD, provides joint recommendations to
address the special needs of these populations (Attachment 2). As
mirrored in the DoD Report (Attachment 3), these recommendations focus on the
capture of lessons learned, the knowledge and technology transfers to be
gained from successful VA/DoD data exchange initiatives, the adoption of
common standards and terminologies to promote more effective and rapid
development of health technologies, and the development of telehealth
technologies to improve care in rural and remote areas.
The DoD has significant experience in delivering care in isolated
conditions such as those encountered in wartime or overseas peacekeeping
missions, which can be compared to the conditions in some rural health care
environments. Examples of the technologies used in these conditions
include telehealth for radiology, mental health, dermatology, pathology, and
dental consultations; online personalized health records for beneficiary use;
bed regulation for disaster planning; basic patient encounter documentation;
pharmacy, radiology, and laboratory order entry and results retrieval for use
in remote areas and small clinics; pharmacy, radiology, and laboratory order
entry and results retrieval; admissions and discharges; appointments for use
in small hospitals; and online education offerings for health care
providers. Technology products, outcomes, benefits, and cumulative
knowledge will be shared for use within the private sector and local/state
organizations to help guide their planning efforts (see Attachment 3 for more
details).
The VA's report, "Approaches to Make Health Information Systems
Available and Affordable to Rural and Medically Underserved Communities"
(Attachment 2), also highlights its successful strategy to develop
high-quality EHR technologies that remain in the public domain. These
technologies may be suitable for transfer to rural and medically underserved
settings. VA's primary health information systems and EHR (VistA and
the Computerized Patient Record System [the current system] and
HealtheVet-VistA, the next generation in development) provide leading
government/public-owned health information technologies that support the
provision, measurement, and improvement of quality, affordable care across
1300 VA inpatient and ambulatory settings. The VA continues to make a
version of VistA available in the public
domain as a means of fostering widespread development of high-performance EHR
systems. The VA is also incorporating the CHI approved standards into
its next-generation HealtheVet-VistA. Furthermore, the VA is developing
PHR technologies such as My HealtheVet, which are consistent with the larger
strategic goal of making veterans (persons) the center of health care.
Finally, the VA's health information technologies, such as bar code
medication administration, VistA Imaging, and telehealth applications,
provide the VA with exceptional tools that improve patient safety and enable
the increasingly geographically dispersed provision of care to patients in
all settings. These and other technologies are proposed as federal
technology transfer options in furtherance of the President's goals.
Conclusion
Health information technology has the potential to transform health care
delivery, bringing information where it is needed and refocusing health care
around the consumer. This can be done without substantial regulation or
industry upheaval. It can give us both better care - care that is higher
in quality, safer, and more consumer responsive - and more efficient care -
care that is less wasteful, more appropriate, and more available. The
changes that will accompany the full use of information technology in the
health care industry will pose challenges to longstanding assumptions and
practices. However, these changes are needed, beneficial, and
inevitable. Action should be taken now to achieve the benefits of
HIT. A well-planned and coordinated effort, sustained over a number of
years, can deliver results that will better support America's
health care professionals and better serve the public.
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