Health information technology (HIT)—or technology that supports storage, retrieval, sharing, and use of health care information for communication and decision-making within and across health care organizations—is being pursued by public agencies and private health care entities across the U.S. State governments support HIT adoption in many ways, motivated by the potential of HIT to improve health care quality and patient safety, and to promote greater value in public health care programs as well as in the broader health care system. States are also motivated by major federal funding opportunities.
Range of State Roles and HIT Activities
According to the findings of the 2007 Health Management Associates/National Governors Association survey of state HIT efforts, states are playing a variety of roles in promoting HIT:
- development and adoption of HIT in Medicaid and the Children's Health Insurance Program;
- use of HIT in public health efforts; and
- promotion of private sector activities by providing funding and data and serving as partners, facilitators, or neutral conveners.
Nearly all state governments have taken on the challenge of promoting and implementing HIT-related policies and encouraging public- and private-sector e-health efforts. The strategies and approaches vary, depending on each state's economy, leadership, allocation of resources, and level of activity among health care providers and purchasers.
State HIT efforts generally involve developing, implementing, and/or supporting adoption of electronic medical/health records, health information exchanges, and others tools described in Figure 1. There is broad agreement that these tools can reduce errors and duplication, enhance access to care, promote evidence-based medicine, and improve quality and efficiency.
Figure 1: Major Types of Health Information Technology
· Electronic medical/health records (EMR/EHR): computerized records that provide clinicians with real-time access to information about a patient's medical history, prescriptions and test orders, and physician notes. The records also may include applications that provide clinical decision support or collect data for quality monitoring or public health reporting.
· Health information exchanges (HIE): an electronic network that shares health information across organizations and information systems. An HIE can operate at a state, regional, or local level.
· e-Prescribing: software that enables providers to order and transmit prescriptions electronically. Medication information can be transmitted not only from a prescriber to a dispenser, but also to health plans or pharmacy benefit managers.
· Electronic clinical decision support: a range of computerized tools that make information relevant to patient care available to providers and patients, including reminders about preventive care, information from clinical guidelines, or patient data reports. Clinical decision support tools are generally used in conjunction with EHRs.
· Telehealth: Telehealth uses phone and/or online communication to provide services to patients. Telehealth can include live videoconferencing between two health care facilities, "store-and-forward" systems that temporarily capture and send digital images or other clinical information from the point of care to another location, remote patient monitoring, and "e-visits" via email or phone.
· Personal health records (PHR) and health/medical record banks : A PHR is an electronic application that enables patients to securely access and manage their health information, including clinical and insurance information. In health or medical record banks, a sponsoring organization such as a government agency collects patients' paper and electronic medical records from various providers and sources and stores PHRs on a Web site. Patients control what and how information is shared.
Sources: V. K. Smith, K. Gifford, S. Kramer et al., State E-Health Activities in 2007: Findings from A State Survey. The Commonwealth Fund and Health Management Associates, February 2008; The Office of the National Coordinator for Health Information Technology, Health IT Tools, accessed October 1, 2009.
Minnesota, Wisconsin, and Vermont are among the states involved in cutting-edge HIT initiatives to support evidence-based medicine and improve patient care through transparent reporting of health outcomes and costs. Arizona and Delaware are among the states with operational health insurance exchanges, and New York has successfully fostered health information technology use among community hospitals and physician practices through its HEAL NY (Healthcare Efficiency and Affordability Law for New Yorkers) and other programs; these state initiatives are described in this issue's Snapshots.
On the horizon are medical record banks, in which consumers are the "gatekeepers" of their medical information, or personal health records (PHRs). For example, Washington State is launching health record banks in three communities. Personal health records are increasingly available to consumers through major technology providers such as Google and Microsoft that offer free Web-based PHRs.
Interoperable, Meaningful, and Transformational
According to Tony Rodgers, director of Arizona's Medicaid program (Arizona Health Care Cost Containment System, AHCCCS) and a leader in state HIT, the long-term goal of state HIT efforts is "to build an electronic health information infrastructure to transform health care delivery."
This requires widespread adoption of EHRs and interoperability, or the ability to transmit patient information across sites. Primary care providers (PCPs) would be able to view health and medication histories, test results, and other information at the point of care. Information would move from primary care providers to hospitals, specialists, managed care organizations, and back again. Such sharing lays the groundwork for better-integrated and coordinated care; it can reduce duplication of services and adverse medication interactions. If such systems become widespread and providers use them to proactively monitor and coordinate patient care, HIT has great potential to improve quality of care and control costs.
But Rodgers points out significant additional benefits of HIT that could foster more comprehensive redesign of the health care system. Interoperable health information across different sites enables the aggregation and tracking of episodes of care around clinical data, facilitating new models of care delivery such as medical homes. It also facilitates transparency to more easily identify unnecessary costs, and supports new payment and delivery models such as "accountable care organizations" (which are groups of physicians and other providers who take joint responsibility for the quality of care and outcomes for their patients, as well as the overall cost of care). "You can't have system redesign without electronic systems and transparency," said Rodgers.
Federal Support for State HIT
Over time, the federal government has taken an increasingly larger role in guiding and supporting state-level HIT. It has provided funding for HIT through Medicaid Transformation Grants to states, through the Agency for Healthcare Research and Quality, and through the Health Resources and Services Administration for federally qualified health centers, rural health clinics, and telehealth efforts. It is now expanding its role through the HITECH Act (Health Information Technology for Economic and Clinical Health Act) of the American Recovery and Reinvestment Act of 2009 (ARRA), also known as the stimulus plan. The Act includes major federal investments and policy changes intended to set a long-term course for HIT adoption in the states. David Blumenthal, M.D., national coordinator for health information technology (see this issue's "Ask the Expert" Q&A), leads the effort at the Department of Health and Human Services, Office of the National Coordinator (ONC), to oversee the federal HIT grants to support the adoption of health information technology and the promotion of nationwide health information exchange to improve the quality of health care. The federal government hopes that such efforts will reduce federal health costs by an estimated $12 billion over 10 years.
Since 2007, Medicaid Transformation Grants have provided $150 million to 35 states, the District of Columbia, and Puerto Rico to improve effectiveness and efficiency in Medicaid. Most of the grants focused on HIT including EHR, e-prescribing, clinical decision support, and HIE. According to a status update by the Centers for Medicare and Medicaid Services, by early 2009 Alabama, Arizona, and New Mexico had begun implementation of EHRs for Medicaid beneficiaries; Delaware, New Mexico, Florida, and Tennessee had implemented e-prescribing projects; Montana had added clinical decision support tools to its EHR for Medicaid providers; Indiana and Wisconsin had begun HIE projects, and other states had made progress in various HIT activities.
ARRA HITECH grants totaling over $40 billion represent a new direction. "The stimulus funding represents a major shift in the federal approach to HIT adoption," said Shaun Alfreds, HIT program manager at the National Academy for State Health Policy. "The total amount of funding available is unprecedented, and the prescriptive role of federal oversight to move states forward on HIT is a real change from the 'see the market' approach by the previous administration."
Two ARRA programs totaling about $1.2 billion are just getting under way:
- the State Health Information Exchange Cooperative Agreement program is offering $564 million for state HIE development (full proposals were due October 16 and awards will be announced December 15, 2009); and
- the HIT extension program is offering $643 million for HIT regional centers to provide technical assistance and support EHR adoption (three funding cycles during 2009–10).
Through grant requirements and task forces, the federal government is greatly expanding its role in setting standards for state HIT efforts. A Health IT Standards Committee is advising the national coordinator on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information. "States are responding fast, in part because of their dire fiscal condition," said Alfreds. "And because the benefits and economies of scale of many HIT tools require large networks, new federal standards could help the HIT marketplace take hold on a dramatically larger scale."
ARRA also provides funding for incentives to promote "meaningful use" of EHRs by hospitals and clinicians participating in Medicare and Medicaid. Bonus payments to providers who can demonstrate meaningful use of EHRs will be paid during 2011–14, and providers who have not done so by 2015 will be subject to penalties. The ONC Policy Committee is developing recommendations on what constitutes meaningful use, and CMS plans to issue a proposed regulation defining meaningful use. CMS recently sent a letter to state Medicaid directors providing guidance on this incentive program.
Finally, the national health care reform bills have provisions to further promote HIT related to: developing standards for data collection, facilitating better data sharing, or aligning health coverage eligibility and enrollment systems with clinical HIT systems.
While federal HIT grants and standards mean that states will lose some independence and face greater oversight, advantages include major funding (at a time when many states are cutting programs and initiatives) and the potential for greater economies of scale, quality control, and interoperability across as well as within state health care systems.
Challenges and Lessons
States have been prime learning laboratories for testing HIT models, technologies, incentives, partnerships, and tools. They have achieved major accomplishments, but have faced many challenges. For example, states continue to struggle with privacy and consent issues, procurement process delays, slow adoption by providers, and lack of funding. In Arizona, about half of HIE development costs were expended addressing legal and policy issues (described in this issue's Snapshots). Ongoing challenges include not only getting affordable hardware and software to practitioners—particularly small practices—but getting them to use it effectively and proactively to improve care.
"A challenge is to work with small practices and hospitals to achieve meaningful use of technology, to raise all boats, so no one is left behind in this technology revolution," says Rodgers. New York City's Primary Care Information Project, featured in this issue's Snapshots, is making important headway in this area.
Perhaps the greatest challenge for states is how to create a sustainable business model for HIT, particularly for a state-wide HIE. What would the HIE look like? How would it be governed, for example is such an enterprise best suited for private ownership or as a public utility? How could savings be captured to sustain the program , for example through user fees or assessments?
As states forge ahead with HIT, they are learning valuable lessons. The Medicaid Transformation Grant program revealed the need for states to coordinate with other e-health initiatives and private stakeholders, and to provide incentives and/or financial assistance to practices to encourage or enable HIT adoption. It also found that broad implementation of HIT was more time-consuming than anticipated, with three years emerging as a realistic minimum.
Based on Arizona's experience developing an HIE, Tony Rodgers stresses three key ingredients for successful statewide, interoperable HIT:
- Leadership –a Medicaid director or governor with a long-term vision for health delivery system redesign; (this can be a challenge given term limits of elected officials, turnover of staff, and learning curve required to educate new people on the issues).
- Willingness to invest – HIT implementation requires extensive planning, such as a state-wide assessment and readiness review to learn what is already in place, identify gaps, and estimate how much support providers need. This should include surveys and focus groups with physicians, hospitals, nursing homes, and other care providers. It also involves bringing CEOs of hospitals, health plans, and the state Medicaid agency to the table and educating them about the importance and benefits of HIT.
- Establishing a legal framework – developing standards and contracts allowing data partners to exchange information with the data users and to overcome competition, privacy, and confidentiality issues.
Rodgers believes that federal leadership and grant programs are extremely helpful, but "HIT is still essentially a state-by-state endeavor. Most states will be able to achieve widespread adoption by 2014, while some will have difficulty and need additional assistance."
