Health data standards are technical requirements used to, among other  things, facilitate health information exchange and interoperability of  systems, including EHR systems. Such standards consist of terminology  and technical specifications that, when adopted by multiple entities,  facilitate the exchange and interoperability of health information. Some of these requirements  include the exchange of health information, which is a component of  interoperability. Initiatives Described a Variety of Approaches for Addressing Interoperability and Are Generally Works in Progress Selected Initiatives Vary in a Number of Ways, Including Their Products or Services and Membership

The initiatives we reviewed vary in their efforts to achieve or facilitate  interoperability, including (1) the primary products or services they offer  (e.g., a network or guidance for implementing standards), (2) the types   of electronic systems the initiatives are working to make interoperable,   (3) the cost of the initiatives’ products or services, (4) the geographic  areas served by the initiatives, (5) the extent to which initiatives facilitate  patient access to their health information, (6) the stakeholder groups that  are members of the initiatives, and (7) the sources of funding for the  initiatives. Most of the Selected Interoperability Initiatives Are Relatively New and Still Undergoing Development

The majority of the initiatives we selected are works in progress, meaning  that they are relatively new and therefore still in the process of  developing, or encouraging others to adopt, their products or services. Representatives from 6 of the initiatives said that their primary products or  services were available in some areas or available on a limited scale;  however, according to the representatives, none of their products or  services were widely available or widely used at the time of our review. Initiative representatives also identified other issues  beyond the scope of their initiatives that they say need to be addressed in  order to move nationwide EHR interoperability forward. Stakeholders and Initiative Representatives Described Five Key Challenges to EHR Interoperability

Stakeholders and representatives from the selected EHR initiatives  described five key challenges to achieving EHR interoperability:   (1) insufficiencies in standards for EHR interoperability, (2) variation   in state privacy rules, (3) accurately matching patients’ health records,   (4) costs associated with interoperability, and (5) need for governance  and trust among entities. For example, as the next section describes, certain  agreements may need to be established as a precondition to  interoperability. Each Key Interoperability Challenge Is in the Process of Being Addressed by at Least Some Initiatives

Representatives from all 18 of the initiatives we reviewed said they are  working to address these key challenges using different approaches (see  table 1). Costs Associated with Interoperability

Sixteen of the 18 initiatives are working to address the challenge of the  reported high costs associated with interoperability. Six initiative representatives  said that improvements to EHR systems—such as enhancements that  improve providers’ workflow or clinical decision-making—are needed  to increase the extent to which an EHR system, and the information  contained within it, is a valuable tool for health care providers. Agency Comments

We provided a draft of this report to HHS for comment. HHS provided  technical comments, which we incorporated as appropriate. Appendix I: Selected Nonfederal Initiatives GAO Reviewed

We identified nonfederal organizations that have ongoing initiatives that  are working to facilitate electronic health record (EHR) interoperability.
Why GAO Did This Study

EHR interoperability is viewed by many health care stakeholders as a necessary step toward improving health care. However, interoperability has remained limited. Although the federal government plays a key role in guiding movement toward interoperability, many of the actions are to be completed by nonfederal stakeholders.
GAO was asked to review the status of efforts by entities other than the federal government to develop infrastructure that could lead to nationwide interoperability of health information. This report describes the (1) characteristics of selected nonfederal initiatives intended to facilitate EHR interoperability, and (2) key challenges related to EHR interoperability and the extent to which selected nonfederal initiatives are addressing these challenges. GAO interviewed representatives from 18 selected nonfederal initiatives that were frequently mentioned by stakeholders GAO interviewed, and reflected a range of approaches. GAO reviewed documents from these initiatives as well as other published research.

What GAO Found

Representatives from the 18 nonfederal initiatives GAO reviewed described a variety of efforts they are undertaking to achieve or facilitate electronic health record (EHR) interoperability, but most of these initiatives remain works in progress. EHR interoperability is the ability of systems to exchange electronic health information with other systems and process the information without special effort by the user, such as a health care provider. These initiatives' efforts include creating guidance related to health data standards, encouraging the adoption of certain health data standards or policies that facilitate interoperability, and operating networks that connect EHR systems to enable interoperability. The initiatives varied in a number of other ways, including the types of electronic systems the initiatives are working to make interoperable, the cost of their products or services, the geographic area served, patient use of the products or services, and their organizational structures. For example, GAO found that while some initiatives are making their products or services available at no cost, others are charging a fee for their products or services based on the type of entity using the product or service (e.g., individual physician or hospital) or the amount of data exchanged. Similarly, over half of the initiatives were using varying approaches to facilitate patient access to and control over their health information. The majority of the initiatives GAO selected are still in the process of developing, or encouraging others to adopt, their products or services. Most of the initiatives' products or services were not widely available at the time of GAO's review, but initiative representatives anticipated greater availability of their products or services in the next 2 years.
Stakeholders and initiative representatives GAO interviewed described five key challenges to achieving EHR interoperability, which are consistent with challenges described in past GAO work. Specifically, the challenges they described are (1) insufficiencies in health data standards, (2) variation in state privacy rules, (3) accurately matching patients' health records, (4) costs associated with interoperability, and (5) the need for governance and trust among entities, such as agreements to facilitate the sharing of information among all participants in an initiative. Representatives from the 18 initiatives GAO reviewed said they are working to address these key challenges using different approaches. Each key challenge is in the process of being addressed by some initiatives. To move interoperability forward, initiative representatives noted, among other issues, that providers need to see an EHR system as a valuable tool for improving clinical care.
The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.