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Health information technology and health information exchange in New York State: New initiatives in implementation and evaluation
Available online at www.sciencedirect.com
Journal of Biomedical Informatics 40 (2007) S17–S20 www.elsevier.com/locate/yjbin
Health information technology and health information exchange in New York State: New initiatives in implementation and evaluation Lisa M. Kern, Rainu Kaushal
q
*
Department of Public Health, Weill Cornell Medical College, 411 East 69th Street, New York, NY 10021, USA New York-Presbyterian Hospital, 525 East 68th Street, New York, NY 10021, USA Received 10 August 2007 Available online 7 September 2007
Abstract More research is needed to understand the effects of health information technology (HIT) and health information exchange (HIE) on quality, safety, efficiency, finances, consumers and providers in community-based settings. New York State is investing heavily in HIT and HIE adoption through the HEAL NY program. It has already provided $53 million in seed money and requires that grantee organizations match the funds. HITEC (The Health Information Technology Evaluation Collaborative) was established to measure systematically the effects of HIT and HIE on consumers, providers, health care quality, patient safety, public health, and financial return on investment in New York State, as no individual grantee is able to conduct cross-cutting evaluations. The results of these evaluations should inform decisions made by leaders in HIT and HIE in New York State and across the nation. Ó 2007 Elsevier Inc. All rights reserved. Keywords: Health information technology; Health information exchange; Evaluation
1. Introduction As the Institute of Medicine has described, ‘‘Between the health care we have and the care we could have lies not just a gap, but a chasm.’’ [1] Two of the most promising strategies for addressing this ‘‘quality chasm’’ are health information technology (HIT) and health information exchange (HIE) [2]. HIT usually includes use of electronic health records (EHRs) and other technologies in one location, whereas HIE involves the sharing of health information electronically across health care settings. HIT has been found to increase adherence to clinical guidelines (especially for preventive care), enhance surveillance and monitoring, decrease medication errors, and decrease utilization [3]. However, a systematic review by q
The authors have no financial conflicts of interest to disclose. Corresponding author. Address: Department of Public Health, Weill Cornell Medical College, 411 East 69th Street, New York, NY 10021, USA. Fax: +1 212 746 8544. E-mail address: [email protected] (R. Kaushal). *
1532-0464/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jbi.2007.08.010
Chaudhry and colleagues found that this literature has been shaped largely by the experience of four benchmark institutions (the Regenstrief Institute in Indiana, Partners Health Care in MA, LDS Hospital/Intermountain Health Care in UT, and the national Veteran Affairs Health Administration) [3]. These institutions developed homegrown systems that were iteratively refined over several decades and may not be generalizable to other academic medical centers, community hospitals or private physician offices that adopt commercially available systems [3]. There is a paucity of data available on the effectiveness of HIE. Among the major barriers to implementing HIT and HIE is the large up-front capital investment required, coupled with uncertain financial returns (in terms of both amount and time horizon). There is also uncertainty about the distribution of potential financial benefits among stakeholders. Two previous studies, based on experts’ estimates, calculated that clinical information exchanges nation-wide would be cost-saving, saving $337–371 billion during implementation and $77–78 billion per year after implementation [4,5]. Other studies, again based on experts’
S18
L.M. Kern, R. Kaushal / Journal of Biomedical Informatics 40 (2007) S17–S20
estimates, asserted that 89% of the return on investment from clinical information exchanges goes to stakeholders other than providers (primarily payers) and that the remaining 11% goes to providers [6,7]. Financial savings are expected to derive from improvements in quality, safety and efficiency, yet no study to date has used primary data of these effects to calculate the return on investment. Several foundations have conducted surveys of patients’ views of HIT and HIE. These surveys have had conflicting results, with some finding that the public is very supportive of HIT and HIE and others finding that the public is more skeptical and concerned with potential breaches of privacy and confidentiality. Little of this work has been published in peer-reviewed journals. The provider experience of HIT and HIE has been shown to be critical for successful implementation. If electronic systems are not designed with usability in mind, this can lead to clinicians abandoning those systems [8,9]. Understanding the unintended consequences of HIT and HIE implementation is also critically important. Unintended consequences may include increasing the work load for clinicians, disrupting work routines, and design flaws that increase the likelihood of errors in care. One threeyear study on the unintended consequences of computerized physician order entry in the inpatient setting found 344 instances of unintended consequences, of which over 25% related to decision support for clinical care [10]. Clearly, more research is needed to understand how HIT and HIE affect quality, safety, efficiency, cost, consumers and providers. This is especially true for commercially available systems that are implemented outside large academic medical centers. 2. The HEAL NY program New York State has made adoption of HIT and HIE a top priority through the Healthcare Efficiency and Affordability Law for New Yorkers (HEAL NY) Capital Grant Program [11]. Although this Grant Program also supports reorganization of hospitals in New York State, we will be discussing only the HIT and HIE initiatives of HEAL NY, which are run by the New York State Department of Health (NYS DOH). The first phase of HEAL NY solicited grant applications in 3 areas: adoption of EHRs, support of electronic prescribing, and development and implementation of community-wide clinical data exchanges. Projects in all of these areas were expected to have components of both HIT and HIE; for example, EHR projects could include creating electronic links among providers in various health care settings (hospitals, private offices, nursing homes, etc.). In May 2006, HEAL NY announced that the first $53 million of a total of $200 million will be awarded to 26 groups across the State [12]. This first phase of HEAL NY alone, which is composed of two-year grants, represents more money per capita than what the federal or most other state governments are spending on HIT and HIE. Of
the 12 other state-wide programs, the majority are spending less than $10 million and none are currently heavily funded by taxpayer dollars [13,14]. The investment in HEAL NY is even greater than the $200 million figure quoted above, because the grantees must match the State’s funds in at least a 1:1 ratio. New York also is unique in the way it has distributed funds for HIT and HIE. For example, MA distributed $50 million to 3 groups, rather than 26 [13]. California is considering investing $240 million in HIT but has not done so yet [15]. In addition to requiring implementation of HIE and requiring 1:1 matching funds, HEAL NY requires that all projects involve multiple stakeholders of various types (e.g. hospitals, physicians, payers, etc.). HEAL NY further requires that all grantees evaluate the effectiveness of their interventions and pay for their evaluations with matching funds (as all State dollars must be dedicated to capital investments). HEAL NY expects that evaluations will include measurement of the project’s impact on health care quality, safety, and cost, as well as consumer and provider satisfaction. 3. The HEAL NY grantees For ease of description, we will refer to all HEAL NY grantees as regional health information organizations (RHIOs), regardless of their underlying organizational structure. HEAL NY Phase 1 awards ranged from $177,503 to $5,000,000 per RHIO, with a mean award of $1.8 million (median $1.7 million). The RHIOs are distributed across 6 geographical regions of New York State: 4 in the Northern region, 4 in the Central region, 3 in the Western region, 2 in the Hudson Valley, 9 in New York City, and 4 on Long Island. A map of the counties covered by each of these geographical regions is available on the website of the New York State Department of Health [12]. Of the 26 RHIOs funded by HEAL NY Phase 1, 17 (65%) plan to adopt EHRs and 17 (65%) plan to adopt electronic prescribing, with 12 (46%) planning to do both of these. All RHIOs (100%) plan to engage in some level of community data exchange. The specific goals of the RHIOs are quite diverse, as illustrated by the following list of selected goals of different RHIOs: exchange data across several emergency departments, use clinical messaging to improve transitions across health care settings, promote electronic prescribing across several counties, develop and implement patient-held ‘‘smart cards’’ for data sharing, implement outpatient electronic medical records, and build a portal for community-wide data exchange. All of the RHIOs plan to use commercially available systems for their initiatives. 4. HITEC If all 26 HEAL NY Phase 1 RHIOs conducted separate evaluations of their initiatives—using different study designs, different sampling strategies, and different outcome
L.M. Kern, R. Kaushal / Journal of Biomedical Informatics 40 (2007) S17–S20
measures—in the end, it would be very difficult to glean generalizable conclusions from this endeavor. That is, using separate evaluations, if one initiative appeared to improve health care quality and another appeared to have no effect on quality, it would be impossible to determine whether this difference in outcome was due to the initiative itself or due to differences in methodology. Thus, with the endorsement of the New York State Department of Health, we founded the Health Information Technology Evaluation Collaborative (HITEC). HITEC is specifically designed to maximize the impact and generalizability of HEAL NY initiatives through the conduct of rigorous evaluations. HITEC is a multi-institutional academic collaborative based at Weill Cornell Medical College, with Dr. Kaushal as the Director and Dr. Kern as the Deputy Director. We bring together local, regional and national experts in the fields of health services research and evaluation methodology, biomedical informatics, health economics, health care policy, and biostatistics. HITEC is being funded through a variety of sources, including grants and contracts from private foundations, government, health plans and the RHIOs themselves. HITEC has 7 work groups, each of which develops metrics for evaluating different aspects of the HEAL NY initiatives: (1) the organizational structure of the RHIOs; (2) the consumer perspective, including views on privacy and security; (3) the provider experience, including quantitative usage metrics and qualitative effects, such as unintended consequences; (4) the impact on quality of care; (5) the impact on patient safety (e.g. medication errors and adverse drug events); (6) the impact on public health; and (7) the financial return on investment, as driven by efficiency, quality and safety (from the perspectives of providers and payers). HITEC is providing various levels of evaluation services to the HEAL NY RHIOs. For some RHIOs, HITEC will be providing survey instruments to measure the patient perspective and provider experience. For other RHIOs, HITEC will be providing the same surveys plus in-depth and personalized guidance on how to measure the impact of their interventions on financial outcomes, quality and safety. All data collection will be performed by the RHIOs themselves. Data analysis will be performed by the RHIOs, HITEC or both. Due to the diversity of initiatives being implemented, it is clear that the RHIOs cannot be combined into a single multicenter trial with universally agreed upon outcome measures. However, it is likely that small groups of RHIOs that are implementing similar initiatives can be combined into several multi-center trials with common outcome measures. 5. Other coordinated efforts to assist RHIOs Several national efforts are assisting RHIOs across the country, though none are solely focused on evaluation methodology. The National Resource Center at the Agency for Healthcare Research and Quality provides
S19
RHIOs with evaluation support, technical assistance for HIT and HIE implementation, and access to their data repository for exchanging ‘‘best practices’’ and lessons learned [16]. The eHealth Initiative is working to increase public awareness about the potential benefits of HIT and HIE, convene multiple stakeholders to promote adoption of HIT and HIE, and stimulate discussions about how RHIOs could achieve financial sustainability [17]. The Markle Foundation’s ‘‘Connecting for Health’’ initiative has developed detailed guidance for RHIOs on how to create appropriate privacy and security policies and created consensus on an initial set of data standards [18]. Several other important evaluation efforts are also occurring across the country. 6. Conclusions In conclusion, New York State is embarking on a novel strategy of promoting adoption of HIT and HIE. It is providing seed money to more entities than any other state government at this time, requiring grant recipients to raise matching funds of their own. It remains to be seen whether this approach will be successful at stimulating sustainable, community-based efforts. The way to maximize understanding about what works and what does not in HEAL NY is to measure systematically the effects of its initiatives on consumers, providers, health care quality, patient safety, public health, and financial return on investment. No single RHIO has the capacity to conduct these cross-cutting evaluations. HITEC was created to contribute methodologic expertise and an independent perspective to the evaluations of many of the HEAL NY RHIOs. The findings of HITEC’s evaluations will be of interest not only to the HEAL NY RHIOs themselves, but to regional, state and national leaders who are exploring ways to fund, design, implement and sustain HIT and HIE initiatives across the country. Acknowledgments We express our deep gratitude to C. William Schroth, Chairman of the Health Information Technology Work Group at the New York State Department of Health, for his vision of HEAL NY and his encouragement to build HITEC. We thank Rachel Block from the United Hospital Fund for her critical insights and guidance. We also thank Ellen Flink, MBA and Anna Colello, JD from the New York State Department of Health for their encouragement. References [1] Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001. [2] Halamka JD. Health information technology: shall we wait for the evidence? Ann Intern Med 2006;144:775–6. [3] Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006;144:742–52.
S20
L.M. Kern, R. Kaushal / Journal of Biomedical Informatics 40 (2007) S17–S20
[4] Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. The adoption of interoperable EMR systems could produce efficiency and safety savings of $142–$371 billion. Health Aff (Millwood) 2005;24:1103–17. [5] Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability. Health Aff (Millwood) 2005;Suppl Web Exclusives:W5-10–8. [6] Middleton B. Achieving U.S. Health information technology adoption: the need for a third hand. Government intervention, judiciously and gently applied, can give the extra assistance needed to boost HIT adoption nationwide. Health Aff (Millwood) 2005;24: 1269–72. [7] Middleton B, Hammond WE, Brennan PF, Cooper GF. Accelerating U.S. EHR adoption: how to get there from here: recommendations based on the 2004 ACMI retreat. J Am Med Inform Assoc 2005;12:13–9. [8] Gainer A, Pancheri K, Zhang J. Improving the human computer interface design for a physician order entry system. AMIA Annu Symp Proc 2003;847. [9] Johnson CM, Johnson TR, Zhang J. A user-centered framework for redesigning heath care interfaces. J Biomed Inform 2005;38:75–87. [10] Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 2006;13:547–56. [11] New York State Department of Health. Request for Grant Applications—HEAL NY Phase 1. Available from: www.health.state.
[12]
[13]
[14]
[15]
[16]
[17] [18]
ny.us/funding/rfa/0508190240. Accessibility verified May 3, 2007. New York State Department of Health. Health Information Technology (HIT) Grants—HEAL NY Phase 1. Available from: www.health.state.ny.us/technology/awards. Accessibility verified May 3, 2007. Foundation of Research and Education of American Health Information Management Association. State level health information exchange initiative development workbook: a guide to key issues, options and strategies. Chicago, 2006. Available from: www.staterhio.org. Accessibility verified May 3, 2007. Avalere Health LLC. Evolution of state health information exchange: a study of vision, strategy and progess (AHRQ Publication No. 06-0057). Rockville (MD): Agency for Healthcare Research and Quality; 2006. California Health Care Foundation. California can lead the way in health information technology: Recommendations to Governor Schwarzenegger’s eHealth Action Forum. Available from: www.chcf.org/topics/view.cfm?itemID=125646&printForum=true. Accessibility verified May 7, 2007. Agency for Healthcare Research and Quality. AHRQ National Resource Center for Health Information Technology. Available from: http://healthit.ahrq.gov. Accessibility verified May 3, 2007. eHealth Initiative. Available from: www.ehealthinitiative.org. Accessibility verified May 3, 2007. Markel Foundation. Connecting for Health. Available from: www.markle.org/markle_programs/healthcare/projects/connecting_for_health.php. Accessibility verified May 3, 2007.
Journal of Biomedical Informatics 40 (2007) S17–S20 www.elsevier.com/locate/yjbin
Health information technology and health information exchange in New York State: New initiatives in implementation and evaluation Lisa M. Kern, Rainu Kaushal
q
*
Department of Public Health, Weill Cornell Medical College, 411 East 69th Street, New York, NY 10021, USA New York-Presbyterian Hospital, 525 East 68th Street, New York, NY 10021, USA Received 10 August 2007 Available online 7 September 2007
Abstract More research is needed to understand the effects of health information technology (HIT) and health information exchange (HIE) on quality, safety, efficiency, finances, consumers and providers in community-based settings. New York State is investing heavily in HIT and HIE adoption through the HEAL NY program. It has already provided $53 million in seed money and requires that grantee organizations match the funds. HITEC (The Health Information Technology Evaluation Collaborative) was established to measure systematically the effects of HIT and HIE on consumers, providers, health care quality, patient safety, public health, and financial return on investment in New York State, as no individual grantee is able to conduct cross-cutting evaluations. The results of these evaluations should inform decisions made by leaders in HIT and HIE in New York State and across the nation. Ó 2007 Elsevier Inc. All rights reserved. Keywords: Health information technology; Health information exchange; Evaluation
1. Introduction As the Institute of Medicine has described, ‘‘Between the health care we have and the care we could have lies not just a gap, but a chasm.’’ [1] Two of the most promising strategies for addressing this ‘‘quality chasm’’ are health information technology (HIT) and health information exchange (HIE) [2]. HIT usually includes use of electronic health records (EHRs) and other technologies in one location, whereas HIE involves the sharing of health information electronically across health care settings. HIT has been found to increase adherence to clinical guidelines (especially for preventive care), enhance surveillance and monitoring, decrease medication errors, and decrease utilization [3]. However, a systematic review by q
The authors have no financial conflicts of interest to disclose. Corresponding author. Address: Department of Public Health, Weill Cornell Medical College, 411 East 69th Street, New York, NY 10021, USA. Fax: +1 212 746 8544. E-mail address: [email protected] (R. Kaushal). *
1532-0464/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jbi.2007.08.010
Chaudhry and colleagues found that this literature has been shaped largely by the experience of four benchmark institutions (the Regenstrief Institute in Indiana, Partners Health Care in MA, LDS Hospital/Intermountain Health Care in UT, and the national Veteran Affairs Health Administration) [3]. These institutions developed homegrown systems that were iteratively refined over several decades and may not be generalizable to other academic medical centers, community hospitals or private physician offices that adopt commercially available systems [3]. There is a paucity of data available on the effectiveness of HIE. Among the major barriers to implementing HIT and HIE is the large up-front capital investment required, coupled with uncertain financial returns (in terms of both amount and time horizon). There is also uncertainty about the distribution of potential financial benefits among stakeholders. Two previous studies, based on experts’ estimates, calculated that clinical information exchanges nation-wide would be cost-saving, saving $337–371 billion during implementation and $77–78 billion per year after implementation [4,5]. Other studies, again based on experts’
S18
L.M. Kern, R. Kaushal / Journal of Biomedical Informatics 40 (2007) S17–S20
estimates, asserted that 89% of the return on investment from clinical information exchanges goes to stakeholders other than providers (primarily payers) and that the remaining 11% goes to providers [6,7]. Financial savings are expected to derive from improvements in quality, safety and efficiency, yet no study to date has used primary data of these effects to calculate the return on investment. Several foundations have conducted surveys of patients’ views of HIT and HIE. These surveys have had conflicting results, with some finding that the public is very supportive of HIT and HIE and others finding that the public is more skeptical and concerned with potential breaches of privacy and confidentiality. Little of this work has been published in peer-reviewed journals. The provider experience of HIT and HIE has been shown to be critical for successful implementation. If electronic systems are not designed with usability in mind, this can lead to clinicians abandoning those systems [8,9]. Understanding the unintended consequences of HIT and HIE implementation is also critically important. Unintended consequences may include increasing the work load for clinicians, disrupting work routines, and design flaws that increase the likelihood of errors in care. One threeyear study on the unintended consequences of computerized physician order entry in the inpatient setting found 344 instances of unintended consequences, of which over 25% related to decision support for clinical care [10]. Clearly, more research is needed to understand how HIT and HIE affect quality, safety, efficiency, cost, consumers and providers. This is especially true for commercially available systems that are implemented outside large academic medical centers. 2. The HEAL NY program New York State has made adoption of HIT and HIE a top priority through the Healthcare Efficiency and Affordability Law for New Yorkers (HEAL NY) Capital Grant Program [11]. Although this Grant Program also supports reorganization of hospitals in New York State, we will be discussing only the HIT and HIE initiatives of HEAL NY, which are run by the New York State Department of Health (NYS DOH). The first phase of HEAL NY solicited grant applications in 3 areas: adoption of EHRs, support of electronic prescribing, and development and implementation of community-wide clinical data exchanges. Projects in all of these areas were expected to have components of both HIT and HIE; for example, EHR projects could include creating electronic links among providers in various health care settings (hospitals, private offices, nursing homes, etc.). In May 2006, HEAL NY announced that the first $53 million of a total of $200 million will be awarded to 26 groups across the State [12]. This first phase of HEAL NY alone, which is composed of two-year grants, represents more money per capita than what the federal or most other state governments are spending on HIT and HIE. Of
the 12 other state-wide programs, the majority are spending less than $10 million and none are currently heavily funded by taxpayer dollars [13,14]. The investment in HEAL NY is even greater than the $200 million figure quoted above, because the grantees must match the State’s funds in at least a 1:1 ratio. New York also is unique in the way it has distributed funds for HIT and HIE. For example, MA distributed $50 million to 3 groups, rather than 26 [13]. California is considering investing $240 million in HIT but has not done so yet [15]. In addition to requiring implementation of HIE and requiring 1:1 matching funds, HEAL NY requires that all projects involve multiple stakeholders of various types (e.g. hospitals, physicians, payers, etc.). HEAL NY further requires that all grantees evaluate the effectiveness of their interventions and pay for their evaluations with matching funds (as all State dollars must be dedicated to capital investments). HEAL NY expects that evaluations will include measurement of the project’s impact on health care quality, safety, and cost, as well as consumer and provider satisfaction. 3. The HEAL NY grantees For ease of description, we will refer to all HEAL NY grantees as regional health information organizations (RHIOs), regardless of their underlying organizational structure. HEAL NY Phase 1 awards ranged from $177,503 to $5,000,000 per RHIO, with a mean award of $1.8 million (median $1.7 million). The RHIOs are distributed across 6 geographical regions of New York State: 4 in the Northern region, 4 in the Central region, 3 in the Western region, 2 in the Hudson Valley, 9 in New York City, and 4 on Long Island. A map of the counties covered by each of these geographical regions is available on the website of the New York State Department of Health [12]. Of the 26 RHIOs funded by HEAL NY Phase 1, 17 (65%) plan to adopt EHRs and 17 (65%) plan to adopt electronic prescribing, with 12 (46%) planning to do both of these. All RHIOs (100%) plan to engage in some level of community data exchange. The specific goals of the RHIOs are quite diverse, as illustrated by the following list of selected goals of different RHIOs: exchange data across several emergency departments, use clinical messaging to improve transitions across health care settings, promote electronic prescribing across several counties, develop and implement patient-held ‘‘smart cards’’ for data sharing, implement outpatient electronic medical records, and build a portal for community-wide data exchange. All of the RHIOs plan to use commercially available systems for their initiatives. 4. HITEC If all 26 HEAL NY Phase 1 RHIOs conducted separate evaluations of their initiatives—using different study designs, different sampling strategies, and different outcome
L.M. Kern, R. Kaushal / Journal of Biomedical Informatics 40 (2007) S17–S20
measures—in the end, it would be very difficult to glean generalizable conclusions from this endeavor. That is, using separate evaluations, if one initiative appeared to improve health care quality and another appeared to have no effect on quality, it would be impossible to determine whether this difference in outcome was due to the initiative itself or due to differences in methodology. Thus, with the endorsement of the New York State Department of Health, we founded the Health Information Technology Evaluation Collaborative (HITEC). HITEC is specifically designed to maximize the impact and generalizability of HEAL NY initiatives through the conduct of rigorous evaluations. HITEC is a multi-institutional academic collaborative based at Weill Cornell Medical College, with Dr. Kaushal as the Director and Dr. Kern as the Deputy Director. We bring together local, regional and national experts in the fields of health services research and evaluation methodology, biomedical informatics, health economics, health care policy, and biostatistics. HITEC is being funded through a variety of sources, including grants and contracts from private foundations, government, health plans and the RHIOs themselves. HITEC has 7 work groups, each of which develops metrics for evaluating different aspects of the HEAL NY initiatives: (1) the organizational structure of the RHIOs; (2) the consumer perspective, including views on privacy and security; (3) the provider experience, including quantitative usage metrics and qualitative effects, such as unintended consequences; (4) the impact on quality of care; (5) the impact on patient safety (e.g. medication errors and adverse drug events); (6) the impact on public health; and (7) the financial return on investment, as driven by efficiency, quality and safety (from the perspectives of providers and payers). HITEC is providing various levels of evaluation services to the HEAL NY RHIOs. For some RHIOs, HITEC will be providing survey instruments to measure the patient perspective and provider experience. For other RHIOs, HITEC will be providing the same surveys plus in-depth and personalized guidance on how to measure the impact of their interventions on financial outcomes, quality and safety. All data collection will be performed by the RHIOs themselves. Data analysis will be performed by the RHIOs, HITEC or both. Due to the diversity of initiatives being implemented, it is clear that the RHIOs cannot be combined into a single multicenter trial with universally agreed upon outcome measures. However, it is likely that small groups of RHIOs that are implementing similar initiatives can be combined into several multi-center trials with common outcome measures. 5. Other coordinated efforts to assist RHIOs Several national efforts are assisting RHIOs across the country, though none are solely focused on evaluation methodology. The National Resource Center at the Agency for Healthcare Research and Quality provides
S19
RHIOs with evaluation support, technical assistance for HIT and HIE implementation, and access to their data repository for exchanging ‘‘best practices’’ and lessons learned [16]. The eHealth Initiative is working to increase public awareness about the potential benefits of HIT and HIE, convene multiple stakeholders to promote adoption of HIT and HIE, and stimulate discussions about how RHIOs could achieve financial sustainability [17]. The Markle Foundation’s ‘‘Connecting for Health’’ initiative has developed detailed guidance for RHIOs on how to create appropriate privacy and security policies and created consensus on an initial set of data standards [18]. Several other important evaluation efforts are also occurring across the country. 6. Conclusions In conclusion, New York State is embarking on a novel strategy of promoting adoption of HIT and HIE. It is providing seed money to more entities than any other state government at this time, requiring grant recipients to raise matching funds of their own. It remains to be seen whether this approach will be successful at stimulating sustainable, community-based efforts. The way to maximize understanding about what works and what does not in HEAL NY is to measure systematically the effects of its initiatives on consumers, providers, health care quality, patient safety, public health, and financial return on investment. No single RHIO has the capacity to conduct these cross-cutting evaluations. HITEC was created to contribute methodologic expertise and an independent perspective to the evaluations of many of the HEAL NY RHIOs. The findings of HITEC’s evaluations will be of interest not only to the HEAL NY RHIOs themselves, but to regional, state and national leaders who are exploring ways to fund, design, implement and sustain HIT and HIE initiatives across the country. Acknowledgments We express our deep gratitude to C. William Schroth, Chairman of the Health Information Technology Work Group at the New York State Department of Health, for his vision of HEAL NY and his encouragement to build HITEC. We thank Rachel Block from the United Hospital Fund for her critical insights and guidance. We also thank Ellen Flink, MBA and Anna Colello, JD from the New York State Department of Health for their encouragement. References [1] Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001. [2] Halamka JD. Health information technology: shall we wait for the evidence? Ann Intern Med 2006;144:775–6. [3] Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006;144:742–52.
S20
L.M. Kern, R. Kaushal / Journal of Biomedical Informatics 40 (2007) S17–S20
[4] Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. The adoption of interoperable EMR systems could produce efficiency and safety savings of $142–$371 billion. Health Aff (Millwood) 2005;24:1103–17. [5] Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability. Health Aff (Millwood) 2005;Suppl Web Exclusives:W5-10–8. [6] Middleton B. Achieving U.S. Health information technology adoption: the need for a third hand. Government intervention, judiciously and gently applied, can give the extra assistance needed to boost HIT adoption nationwide. Health Aff (Millwood) 2005;24: 1269–72. [7] Middleton B, Hammond WE, Brennan PF, Cooper GF. Accelerating U.S. EHR adoption: how to get there from here: recommendations based on the 2004 ACMI retreat. J Am Med Inform Assoc 2005;12:13–9. [8] Gainer A, Pancheri K, Zhang J. Improving the human computer interface design for a physician order entry system. AMIA Annu Symp Proc 2003;847. [9] Johnson CM, Johnson TR, Zhang J. A user-centered framework for redesigning heath care interfaces. J Biomed Inform 2005;38:75–87. [10] Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 2006;13:547–56. [11] New York State Department of Health. Request for Grant Applications—HEAL NY Phase 1. Available from: www.health.state.
[12]
[13]
[14]
[15]
[16]
[17] [18]
ny.us/funding/rfa/0508190240. Accessibility verified May 3, 2007. New York State Department of Health. Health Information Technology (HIT) Grants—HEAL NY Phase 1. Available from: www.health.state.ny.us/technology/awards. Accessibility verified May 3, 2007. Foundation of Research and Education of American Health Information Management Association. State level health information exchange initiative development workbook: a guide to key issues, options and strategies. Chicago, 2006. Available from: www.staterhio.org. Accessibility verified May 3, 2007. Avalere Health LLC. Evolution of state health information exchange: a study of vision, strategy and progess (AHRQ Publication No. 06-0057). Rockville (MD): Agency for Healthcare Research and Quality; 2006. California Health Care Foundation. California can lead the way in health information technology: Recommendations to Governor Schwarzenegger’s eHealth Action Forum. Available from: www.chcf.org/topics/view.cfm?itemID=125646&printForum=true. Accessibility verified May 7, 2007. Agency for Healthcare Research and Quality. AHRQ National Resource Center for Health Information Technology. Available from: http://healthit.ahrq.gov. Accessibility verified May 3, 2007. eHealth Initiative. Available from: www.ehealthinitiative.org. Accessibility verified May 3, 2007. Markel Foundation. Connecting for Health. Available from: www.markle.org/markle_programs/healthcare/projects/connecting_for_health.php. Accessibility verified May 3, 2007.