Today’s economic crisis has highlighted our need for breakthrough improvements in the quality, safety and efficiency of health care. The nation’s business competitiveness is threatened by growing health care costs, while at the same time our citizens risk losing access to care because of unemployment and the decreasing affordability of coverage. Meanwhile, the quality variations and safety shortfalls in our care system have been well documented.
Health IT is not a panacea for all of these challenges, but it is a critical first step toward addressing many of them. Before we can restructure payment systems to reward quality, we need reliable, near real time data on outcomes. Before we can reward teamwork and collaboration that re-integrates care, we need applications that let clinicians communicate patient information instantly and securely. And in order to reverse the growing burden of chronic diseases, we need online connections that engage individuals in their care and motivate them to make healthier lifestyle choices.
Our current, paper-based health information process wastes hundreds of billions of dollars annually. Transforming this into a streamlined twenty-first century electronic system will require many components: a conversion to interoperable electronic health records (EHRs) at healthcare facilities, the adoption of online personal health records (PHRs) for individuals, health information organizations that support and connect these systems to allow information sharing, and finally a national health information network that allows instantaneous secure access – always with appropriate consent from the individual -- wherever and whenever their records are needed.
Where we stand today
There are hundreds of stakeholders in the development and adoption of interoperable health care information technology including consumers, providers, patients, payers, employers, researchers, government agencies, vendors, and standards development organizations. Over the past 20 years, these groups have worked together informally, but until recently there has not been a process to create a single list of priorities or a coordinated project plan. This fragmented approach in many ways mimics the fragmented healthcare delivery system within the US.
In 2004, the Office of the National Coordinator (ONC) within the Department of Health and Human Services (HHS) was established and charged with creating a single strategic plan for all these stakeholders to work together to harmonize health care data standards, create architectures for data exchange, document privacy principles, and certify compliant systems which adhere to best practices. Under ONC/HHS guidance, several groups have successfully implemented this work, leading to demonstrable progress in integrating some aspects of health care delivery. An HHS advisory committee, the American Health Information Community (AHIC), prioritized needs and developed harmonized health IT standards for the country based on multi-stakeholder collaboration around a tool known as a “use case.” It produced 3 use cases in 2006, 4 use cases in 2007, 6 use cases in 2008, and a prioritized list of standards gaps to fill in 2009. The successor to AHIC, the National eHealth Collaborative, is a voluntary consensus standards body that extends the strengths of AHIC by enabling broader private sector and consumer representation. It will continue this work by developing and prioritizing initiatives to solve real implementation challenges in the field.
The Healthcare Information Technology Standards Panel (HITSP), a voluntary group of standards experts, received 13 use cases plus a privacy/security standardization request from AHIC. All of these use cases led to unambiguous interoperability specifications that were delivered within 9 months of receiving the request. The standards were chosen by consensus in an open transparent manner with many controversies resolved along the way.
At this point, standards for personal health record exchange, laboratories, biosurveillance, medications, quality, emergency first responder access to clinical summary data, home health device monitoring, immunizations, genomic data, hospital to hospital transfers of records including imaging data, public health reporting and patient-provider secure messaging are finished. Consequently, standards are no longer a rate limiting step to data exchange in these cases. The Certification Commission for Healthcare Information Technology (CCHIT) has certified over 160 electronic health record products based on detailed functional and standards conformance criteria. It has achieved broad industry recognition as the place to develop a road map for the features and interoperability requirements to include in the yearly revisions of health care IT products.
Using the harmonized standards, the Nationwide Health Information Network, a pilot initiative of HHS, demonstrated a successful architecture for pushing data between stakeholders, for query/response to pull data, and appropriate security protections. Many of these pilots have become production systems in their localities. Working together, thousands of volunteer hours in these organizations have led to policy and technology frameworks that have been embraced by several live health care exchanges including those at the Social Security Administration, eHealth Connecticut, Keystone Health Information Exchange, Boston Medical Center Ambulatory EMR, Vermont Information Technology Leaders, Inc. (VITL), MA-Share (a statewide data exchange), and Beth Israel Deaconess Medical Center.