Medicare and Medicaid EHR Programs

HITECH provided funding for various activities, including the Medicare  and Medicaid EHR programs. These programs are intended to help  increase the meaningful use of EHR technology by providing incentive  payments for, and later imposing penalties on, providers—that is, certain  hospitals and health care professionals such as physicians—who  participate in Medicare or Medicaid. Challenges Are Reported Related to Standards, Privacy, Patient Matching, and Costs of Electronic Exchange

Providers and stakeholders we interviewed cited key challenges to  electronic health information exchange; in particular, they cited issues  related to insufficient standards, concerns about how privacy rules can  vary among states, difficulties in matching patients to their records, and  costs associated with electronic health information exchange. CMS and  ONC officials noted that they have several ongoing programs and  initiatives to help address some aspects of these key challenges, but  concerns in these areas continue to exist. Reported insufficiencies in standards for electronic health  information exchange. Although HHS has ongoing efforts to address the patient matching  challenge, several providers and stakeholders commented that more  work needs to be done on this issue. Providers we interviewed reported challenges covering costs associated  with health information exchange, including upfront costs associated with  purchasing and implementing EHR systems, fees for participation in state  or local HIE organizations, and per-transaction fees for exchanging health  information charged by some vendors or HIE organizations. HHS Developed an Electronic Health Information Exchange Strategy That Includes Principles to Address Key Challenges but Lacks Specific Prioritized Actions and Milestones

HHS, including CMS and ONC, developed and issued a strategy  document in August 2013 that describes how it expects to advance  electronic health information exchange, with principles to guide future  actions in three broad areas—accelerating health information exchange,  advancing standards and interoperability, and patient engagement. The HHS strategy does not provide milestones with  specific time frames to help the agencies gauge their progress in  advancing exchange. Determining specific, prioritized actions and exchange- related milestones with specified time frames can help to ensure that the  agencies’ principles and future actions result in timely improvements in  addressing the key exchange-related challenges reported by providers  and stakeholders, which are particularly important because planning for  Stage 3 is expected to begin as soon as 2014. This information could also  help HHS prioritize its future actions based on whether health information  is being exchanged effectively among providers, in order to better achieve  the EHR programs’ ultimate goals of improving quality, efficiency, and  patient safety. Guidance on planning  and implementing effective strategies highlights the importance of key  elements, such as specific, prioritized actions and milestones for gauging  progress. Recommendations for Executive Action

To address challenges that affect the ability of providers to electronically  exchange health information, we recommend that the Secretary of Health  and Human Services direct CMS and ONC to take the following two  actions: develop and prioritize specific actions that HHS will take consistent  with the principles in HHS’s strategy to advance health information  exchange; and develop milestones with time frames for the actions to better gauge  progress toward advancing exchange, with appropriate adjustments  over time. We selected the four states because they  were mentioned during interviews with officials from HHS and relevant  stakeholders as having ongoing efforts related to health information  exchange. Appendix III: CMS and ONC Principles to Facilitate Health Information Exchange

This appendix provides information on the principles that the Centers for  Medicare & Medicaid Services (CMS) and the Office of the National  Coordinator for Health Information Technology (ONC) plan to use to  guide their future actions to facilitate health information exchange. These  principles are outlined in a strategy that the agencies released in August  2013 to describe how they expect the principles to lead to future actions  that have the potential to address the key challenges providers and  stakeholders have identified relative to electronic health information  exchange in four areas—standards, patients’ privacy, matching patients  with data, and costs.
Why GAO Did This Study

The Health Information Technology for Economic and Clinical Health Act (HITECH) promotes the use of health information technology and identifies the importance of health information exchange. It provides incentive payments to promote the widespread adoption and meaningful use of EHR technology. To be a meaningful user, providers are to demonstrate, among other things, that their certified EHR technology can electronically exchange health information. GAO examined (1) the key challenges to the electronic exchange of health information, if any, that have been reported by providers and stakeholders, and HHS's ongoing efforts to address them, and (2) the extent to which HHS has planned future actions to address those key challenges. GAO reviewed HHS documentation; interviewed HHS officials; and interviewed providers—hospital officials and physicians—and relevant stakeholders about their experiences.

What GAO Found

Providers and stakeholders GAO interviewed in four states with ongoing electronic health information exchange efforts cited key challenges to exchange, in particular, issues related to insufficient standards, concerns about how privacy rules can vary among states, difficulties in matching patients to their records, and costs associated with exchange. Officials from the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC)—agencies within the Department of Health and Human Services (HHS)—noted that they have several ongoing programs and initiatives to help address some aspects of these key challenges, but concerns in these areas continue to exist. For example, several providers GAO interviewed said that they have difficulty exchanging certain types of health information due to insufficient health data standards. Although HHS has begun to address insufficiencies in standards through its Medicare and Medicaid Electronic Health Record (EHR) programs, such as through the introduction of new 2014 standards for certified EHR technology, it is unclear whether its efforts will lead to widespread improvements in electronic health information exchange. In addition, providers GAO interviewed reported challenges covering costs associated with electronic exchange, such as upfront costs associated with purchasing and implementing EHR systems. While HHS is working to address this challenge through various efforts, including a program that helps fund health information exchange organizations—organizations that provide support to facilitate the electronic exchange of health information—some providers told GAO they do not participate in these organizations because they see limited opportunities for exchanging information through them.
HHS, including CMS and ONC, developed and issued a strategy document in August 2013 that describes how it expects to advance electronic health information exchange. The strategy identifies principles intended to guide future actions to address the key challenges that providers and stakeholders have identified. However, the HHS strategy does not specify any such actions, how any actions should be prioritized, what milestones the actions need to achieve, or when these milestones need to be accomplished. GAO's prior work, consistent with the Government Performance and Results Act Modernization Act of 2010 (GPRAMA), sets forth several key elements of strategies that can guide agencies in planning and implementing an effective government program. As noted in GAO's prior work, elements such as specific actions, priorities, and milestones are desirable for evaluating progress, achieving results in specified time frames, and ensuring effective oversight and accountability. Determining specific actions and exchange-related milestones with specified time frames can help to ensure that the agencies' principles and future actions result in timely improvements in addressing the key challenges reported by providers and stakeholders; this is particularly important because planning for Stage 3 of the EHR programs, which focuses on improving outcomes, is expected to begin as soon as 2014. This information could also help CMS and ONC prioritize their future actions based on whether health information is being exchanged effectively among providers, in order to better achieve the EHR programs' ultimate goals of improving quality, efficiency, and patient safety.

What GAO Recommends

GAO recommends that CMS and ONC (1) develop and prioritize specific actions that HHS will take consistent with the principles in HHS's strategy to advance health information exchange, and (2) develop milestones with time frames for the actions to better gauge progress toward advancing exchange, with appropriate adjustments over time. In commenting on the draft report, HHS, including CMS and ONC, concurred with these recommendations.