1.) Five Key Factors Affect EHR Use and Electronic Health Information Exchange in Post-Acute Care Settings

We identified five key factors that affect the use of EHRs and the  electronic exchange of health information in post-acute care settings,  based on our stakeholder interviews: (1) the cost of EHRs, (2)  implementation of standards for EHRs and electronic health information  exchange, (3) the impact of EHRs on workflow, (4) technological  challenges such as lack of EHR capabilities, and (5) the need to train staff  to use EHRs. Concerns included variability in the implementation of standards and the  difficulty of finding relevant information when it is exchanged. For example, stakeholders we  interviewed stated that providers may be reluctant to implement an EHR  because it would require them to make changes to their workflow, which  can be disruptive. Technological Challenges: Sixteen of the 20 stakeholders stated that  technological challenges prevent some facilities from using EHRs or  electronically exchanging health information. In addition to high turnover, stakeholders noted that post-acute care  settings may lack information technology (IT) staff to manage the EHR  software and train staff to use the technology. HHS Has Not Measured the Effectiveness of Each of Its Efforts to Promote the Use of EHRs and Lacks a Comprehensive Plan to Meet Its Goal for Post-Acute Care

		HHS Has Four Key Efforts Designed to Promote the Use of EHRs and the Electronic Exchange of Health Information

ONC and CMS officials identified four key efforts that promote the use of  EHRs in post-acute care settings, including the electronic exchange of  health information. HHS Has Not Measured the Effectiveness of Each of Its Key Efforts to Promote the Use of EHRs and the Electronic Exchange of Health Information in Post-Acute Settings

HHS does not have information on the effectiveness of its four key efforts  to promote EHRs and the electronic exchange of health information in  post-acute settings. In addition to the limited evaluation plans geared specifically for HHS’s  four key efforts, ONC officials told us that ONC is planning to survey  providers in all four post-acute settings to gather baseline information  about the rates of EHR adoption and the extent to which post-acute care  providers are engaging in activities that demonstrate interoperability— specifically, sending, receiving, finding, and integrating electronic health  information. HHS Lacks a Comprehensive Plan with Specific Action Steps and Consideration of External Factors to Achieve Its Goal for Post-Acute Care

HHS’s ongoing activities to increase EHR use and the electronic  exchange of health information are intended to help achieve the goal of  ONC’s Roadmap to increase the proportion of post-acute care providers  electronically exchanging health information by 2017. However, HHS  does not have a comprehensive plan to achieve this goal. According to leading principles of  sound planning identified in our prior work, these elements include a plan  with specific action steps and the identification and consideration of  external factors. 2.) The lack of a comprehensive plan with  specific action steps and the failure to consider external factors, such as  cost and high staff turnover, in the Roadmap may adversely affect the  implementation of HHS’s key efforts and thus the ability of HHS to  achieve the Roadmap’s goal for post-acute providers. HHS officials indicated that while  achieving the goal of the Roadmap depends in part on actions by post- acute care vendors and providers, the Roadmap does not address how to  facilitate or encourage vendor and provider actions. Recommendations for Executive Actions

To improve efforts to promote EHR use and electronic exchange of health  information in post-acute care settings, we recommend that the Secretary  of Health and Human Services direct CMS and ONC to take the following  two actions:
Evaluate the effectiveness of HHS’s key efforts to determine whether  they are contributing to HHS’s goal for increasing the use of EHRs  and electronic exchange of health information in post-acute care  settings.
Why GAO Did This Study

Many patients who leave hospitals receive care in post-acute settings such as skilled nursing facilities and long-term care hospitals. Exchange of accurate and timely health information is particularly important in these transitions, and technology like EHRs could help to improve quality and reduce costs.
GAO was asked to review issues related to the use of EHRs in post-acute care settings. With regard to post-acute settings, GAO (1) described factors that affect EHR use and electronic exchange of health information and (2) examined HHS efforts to promote EHR use and electronic information exchange. GAO reviewed HHS planning and related documents and best practices for planning identified in prior GAO work. GAO also interviewed HHS officials, and through those interviews and background research identified and interviewed a non-generalizable selection of individuals representing 20 relevant stakeholder groups, including experts, vendors, and professional associations.

What GAO Found

Stakeholders that GAO interviewed, including experts on electronic health records (EHR) in post-acute care settings, described five key factors that affect the use of EHRs and the electronic exchange of health information in these settings.
Cost: Stakeholders stated that facilities often have limited financial resources to cover the initial cost of an EHR and noted that additional costs may be incurred for exchanging information and for EHR maintenance.
Implementation of standards: Stakeholders expressed concerns with the variability in implementation of health data standards and the difficulty of finding health information relevant to post-acute care providers when this information is exchanged.
Workflow disruptions: Stakeholders stated that implementation of EHRs requires post-acute facilities to change their daily work activities or processes, which can be disruptive.
Technological challenges: Stakeholders stated that they face technological challenges, such as having EHRs that are not capable of electronically exchanging health information.
Staffing: Stakeholders noted that a lack of staff with expertise to manage EHRs and high staff turnover result in a constant need to train staff to use the technology.
The Department of Health and Human Services (HHS) has not measured the effectiveness of each of its efforts to promote the use of EHRs, and it lacks a comprehensive plan to meet its goal of increasing the proportion of post-acute care providers electronically exchanging health information. HHS identified four key efforts related to post-acute care settings; however, the lack of measurement of the effectiveness of these efforts is contrary to leading principles of sound planning. The Office of the National Coordinator for Health Information Technology (ONC) is planning to survey providers in post-acute settings to gather baseline data on the rates of EHR adoption and activities that demonstrate ways to electronically exchange health information. However, these surveys are not intended to assess the effectiveness of HHS's efforts to promote EHR use. In addition, most of the key efforts lack specific plans for evaluating their progress. Therefore, HHS cannot determine if its efforts are contributing to its goal, or if they should be adjusted. In addition, although HHS's goal depends in part on actions by post-acute care providers and EHR vendors, HHS lacks a comprehensive plan with specific action steps to achieve this goal. HHS's planning also does not address how to overcome key external factors that may adversely affect its key efforts. Without a comprehensive plan to address these issues, HHS risks not achieving its goal of increasing EHR use and the electronic exchange of health information in post-acute care settings.

What GAO Recommends

GAO recommends that HHS (1) evaluate the effectiveness of its key efforts to increase the use of EHRs and electronic information exchange, and (2) comprehensively plan for how to achieve the department's goal regarding the use of EHRs and electronic information exchange in post-acute care settings. HHS concurred with GAO's recommendations.