Julia Adler-Milstein

U.S. Regional Health Information Organizations: Progress And Challenges

We surveyed regional health information organizations (RHIOs) to assess the state of electronic health information exchange in the United States. We found fifty-five operational RHIOs, and most were focused on exchanging test results. Forty-one percent of operational RHIOs reported receiving sufficient revenue from participating entities to cover operating costs. Of the remainder, only 28 percent expected to ever do so. RHIOs in the planning stage were far more optimistic. Operational RHIOs from our 2007 survey had made little progress in expanding the breadth of their activities. Although the number of operational RHIOs is growing, their scope remains limited and their viability uncertain.

A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use

BACKGROUND To receive financial incentives for meaningful use of electronic health records, physicians and hospitals will need to engage in health information exchange (HIE). For most providers, joining regional organizations that support HIE is the most viable approach currently available. OBJECTIVE To assess the state of HIE in the United States through regional health information organizations (RHIOs). DESIGN Survey. SETTING All RHIOs in the United States. PARTICIPANTS 179 U.S.-based RHIOs that facilitated HIE as of December 2009. MEASUREMENTS Number of operational RHIOs, the subset of operational RHIOs that supported stage 1 meaningful use, and the subset that supported robust HIE; number of ambulatory practices and hospitals participating in RHIOs; and number of financially viable RHIOs. RESULTS Of 197 potential RHIOs, 179 (91%) reported their status and 165 (84%) returned completed surveys. Of these, 75 RHIOs were operational, covering approximately 14% of U.S. hospitals and 3% of ambulatory practices. Thirteen RHIOs supported stage 1 meaningful use (covering 3% of hospitals and 0.9% of practices), and none met an expert-derived definition of a comprehensive RHIO. Overall, 50 of 75 RHIOs (67%) did not meet the criteria for financial viability. LIMITATIONS Survey data were self-reported. The sample may not have included all HIE efforts, particularly those of individual providers who set up their own data-exchange agreements. CONCLUSION These findings call into question whether RHIOs in their current form can be self-sustaining and effective in helping U.S. physicians and hospitals engage in robust HIE to improve the quality and efficiency of care. PRIMARY FUNDING SOURCE Office of the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services.

More Than Half of US Hospitals Have At Least A Basic EHR, But Stage 2 Criteria Remain Challenging For Most

The national effort to promote the adoption and meaningful use of electronic health records (EHRs) is well under way. However, 2014 marks an important transition: For many hospitals, penalties will be assessed in fiscal year 2015 for failing to meet federal meaningful-use criteria by the end of fiscal year 2014. We used recent data from the American Hospital Association Annual Survey of Hospitals--IT Supplement to assess progress and challenges. EHR adoption among US hospitals continues to rise steeply: 59 percent now have at least a basic EHR. Small and rural hospitals continue to lag behind their better resourced counterparts. Most hospitals are able to meet many of the stage 2 meaningful-use criteria, but only 5.8 percent of hospitals are able to meet them all. Several criteria, including sharing care summaries with other providers and providing patients with online access to their data, will require attention from EHR vendors to ensure that the necessary functions are available and additional effort from many hospitals to make certain that these functionalities are used. Policy makers may want to consider new targeted strategies to ensure that all hospitals move toward meaningful use of EHRs.

Electronic Health Record Adoption In US Hospitals: Progress Continues, But Challenges Persist

Achieving nationwide adoption of electronic health records (EHRs) remains an important policy priority. While EHR adoption has increased steadily since 2010, it is unclear how providers that have not yet adopted will fare now that federal incentives have converted to penalties. We used 2008-14 national data, which includes the most recently available, to examine hospital EHR trends. We found large gains in adoption, with 75 percent of US hospitals now having adopted at least a basic EHR system--up from 59 percent in 2013. However, small and rural hospitals continue to lag behind. Among hospitals without a basic EHR system, the function most often not yet adopted (in 61 percent of hospitals) was physician notes. We also saw large increases in the ability to meet core stage 2 meaningful-use criteria (40.5 percent of hospitals, up from 5.8 percent in 2013); much of this progress resulted from increased ability to meet criteria related to exchange of health information with patients and with other physicians during care transitions. Finally, hospitals most often reported up-front and ongoing costs, physician cooperation, and complexity of meeting meaningful-use criteria as challenges. Our findings suggest that nationwide hospital EHR adoption is in reach but will require attention to small and rural hospitals and strategies to address financial challenges, particularly now that penalties for lack of adoption have begun.

Does health information exchange reduce redundant imaging? Evidence from emergency departments.

Background:Broad-based electronic health information exchange (HIE), in which patients’ clinical data follow them between care delivery settings, is expected to produce large quality gains and cost savings. Although these benefits are assumed to result from reducing redundant care, there is limited supporting empirical evidence. Objective:To evaluate whether HIE adoption is associated with decreases in repeat imaging in emergency departments (EDs). Data Source/Study Setting:ED discharge data from the State Emergency Department Databases for California and Florida for 2007–2010 were merged with Health Information Management Systems Society data that report hospital HIE participation. Methods:Using regression with ED fixed effects and trends, we performed a retrospective analysis of the impact of HIE participation on repeat imaging, comparing 37 EDs that initiated HIE participation during the study period to 410 EDs that did not participate in HIE during the same period. Within 3 common types of imaging tests [computed tomography (CT), ultrasound, and chest x-ray), we defined a repeat image for a given patient as the same study in the same body region performed within 30 days at unaffiliated EDs. Results:In our sample there were 20,139 repeat CTs (representing 14.7% of those cases with CT in the index visit), 13,060 repeat ultrasounds (20.7% of ultrasound cases), and 29,703 repeat chest x-rays (19.5% of x-ray cases). HIE was associated with reduced probability of repeat ED imaging in all 3 modalities: −8.7 percentage points for CT [95% confidence interval (CI): −14.7, −2.7], −9.1 percentage points for ultrasound (95% CI: −17.2, −1.1), and −13.0 percentage points for chest x-ray (95% CI: −18.3, −7.7), reflecting reductions of 44%–67% relative to sample means. Conclusions:HIE was associated with reduced repeat imaging in EDs. This study is among the first to find empirical support for this anticipated benefit of HIE.

Telehealth Among US Hospitals: Several Factors, Including State Reimbursement And Licensure Policies, Influence Adoption

Telehealth is widely believed to hold great potential to improve access to, and increase the value of, health care. Gaining a better understanding of why some hospitals adopt telehealth technologies while others do not is critically important. We examined factors associated with telehealth adoption among US hospitals. Data from the Information Technology Supplement to the American Hospital Associations 2012 annual survey of acute care hospitals show that 42 percent of US hospitals have telehealth capabilities. Hospitals more likely to have telehealth capabilities are teaching hospitals, those equipped with additional advanced medical technology, those that are members of a larger system, and those that are nonprofit institutions. Rates of hospital telehealth adoption by state vary substantially and are associated with differences in state policy. Policies that promote private payer reimbursement for telehealth are associated with greater likelihood of telehealth adoption, while policies that require out-of-state providers to have a special license to provide telehealth services reduce the likelihood of adoption. Our findings suggest steps that policy makers can take to achieve greater adoption of telehealth by hospitals.

Sharing Clinical Data Electronically: A Critical Challenge for Fixing the Health Care System

THE UNITED STATES IS UNDERTAKING AN AMBITIOUS EFfort to wire the health care system. The goal is to build a nationwide information infrastructure to serve as the foundation for large and sustained improvements in performance. Widespread adoption of health information technology will support new care delivery models, such as patient-centered medical homes, alongside broader initiatives, such as performance reporting and public health surveillance. To enable the health information technology revolution, Congress allocated nearly

Benchmarking health IT among OECD countries: better data for better policy

30 billion focused on 2 main goals: transitioning physicians and hospitals from paper-based to electronic systems and enabling these systems to interoperate, allowing clinical data to flow between health care organizations. The vision of complete patient information available across care delivery settings is compelling and central to a highfunctioning health care system. However, the vision is deceptively simple: there are enormous challenges to enabling clinical data to flow across organizations. These challenges are substantially greater than those associated with transitioning physicians and hospitals to electronic health records. Health information exchange (HIE) is the act of sharing clinical data among health care practitioners and practice settings (physicians, hospitals, nursing homes, etc) who are not part of the same organizational entity. Although most electronic health records make clinical data sharing within the same organization relatively easy, sharing across organizations is difficult. Before passage of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, policy makers primarily focused on regional health information organizations (RHIOs) to promote HIE. RHIOs brought together physicians, hospitals, and other health care stakeholders in the local community to establish core principles for how they could exchange data with each other. Despite substantial funding from state and federal governments, these organizations have made slow progress in enabling broad exchange and finding sustainable business models. Under HITECH, policy makers are pursuing a more flexible multipronged approach to HIE. First, they included the ability to engage in HIE (ie, share clinical data electronically with others) in the criterion for “meaningful use,” the federal standard for incentives to health care practitioners and hospitals for using an electronic health record. In the future, meaningful use will likely require that clinicians actually engage in HIE, not just demonstrate the ability. Part of the motivation for beginning with less stringent requirements is that even for clinicians and health care organizations with an electronic health record, there are few accessible, affordable options for sending and receiving data electronically across organizations. Therefore, a second part of the federal approach is to engage states in creating such options. In 2010, the US Department of Health and Human Services awarded more than

Health information exchange among U.S. hospitals: who's in, who's out, and why?

548 million through the State HIE Cooperative Agreement Program. Over the 4-year program period, states are responsible for ensuring adequate infrastructure to allow for sharing clinical data across care settings. States are in the early stages of implementing their plans and are pursuing a variety of strategies. A third facet of the federal approach is to promote the Direct Project, a set of services that rely on the Internet to securely push data from one authorized user to another. The Direct Project essentially operates like an e-mail inbox, with added security and authorization, and is a relatively simple and inexpensive approach to HIE. The long-term plan is to evolve from clinicians pushing data (ie, sending an e-mail) to searching for individual patients and retrieving their data, with the hope that HIE will be seamless and will require little work by the clinician to search for information outside of the electronic health record. Whether these efforts will successfully result in broadbased HIE is unclear. According to Blumenthal, the Obama Administration’s former point person on health information technology, HIE is one of the “major challenges in delivering on the ambitious agenda of the HITECH Act.” There are at least 5 major barriers, 3 of which seem under federal policy makers’ control. The first is data privacy and security. There remains uncertainty among clinicians about the legal ramifications of a data breach or unauthorized access through HIE. Second, the Direct Project promotes point-

Effect of electronic health records on health care costs: longitudinal comparative evidence from community practices.

OBJECTIVE To develop benchmark measures of health information and communication technology (ICT) use to facilitate cross-country comparisons and learning. MATERIALS AND METHODS The effort is led by the Organisation for Economic Co-operation and Development (OECD). Approaches to definition and measurement within four ICT domains were compared across seven OECD countries in order to identify functionalities in each domain. These informed a set of functionality-based benchmark measures, which were refined in collaboration with representatives from more than 20 OECD and non-OECD countries. We report on progress to date and remaining work to enable countries to begin to collect benchmark data. RESULTS The four benchmarking domains include provider-centric electronic record, patient-centric electronic record, health information exchange, and tele-health. There was broad agreement on functionalities in the provider-centric electronic record domain (eg, entry of core patient data, decision support), and less agreement in the other three domains in which country representatives worked to select benchmark functionalities. DISCUSSION Many countries are working to implement ICTs to improve healthcare system performance. Although many countries are looking to others as potential models, the lack of consistent terminology and approach has made cross-national comparisons and learning difficult. CONCLUSIONS As countries develop and implement strategies to increase the use of ICTs to promote health goals, there is a historic opportunity to enable cross-country learning. To facilitate this learning and reduce the chances that individual countries flounder, a common understanding of health ICT adoption and use is needed. The OECD-led benchmarking process is a crucial step towards achieving this.