Policy initiatives for Health Information Technology: A qualitative study of U.S. expectations and Canada's experience

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Abstract

Objective

To investigate lessons learned from national policy initiatives in Canada and U.S. with respect to health information technical infrastructure, data standards, and interoperability; and to identify the implications of these lessons for other policy makers, as they guide the future of their own healthcare information technology initiatives.

Materials and methods

We performed semi-structured interviews with key opinion leaders including health care professionals, chief information officers, and vendors – 29 in Canada and 31 in the U.S., regarding Health Information Technology policy. The informant sample was chosen to provide views from different stakeholder groups, and included both national and regional representation – three Canadian provinces and three U.S. states. A grounded theory approach was used to analyze the data gathered through the interviews.

Results

The informants identified the following key components of successful health IT policy: (1) enables an iterative-incremental management approach to both technology and data standards, (2) addresses the issues around meaningful use and investment already made in existing legacy health IT systems; and (3) capitalizes on the value of data for use in performance and quality measures, public health and research.

Conclusions

Our study has found that successful health information exchange depends on policies that set clear goals and outline intended effects of HIT implementation without being overly prescriptive, and defines frameworks for guiding policy improvement in a continual and systematic manner. The success of health information exchange also depends on the ability to manage an iterative-incremental approach to technology and data standards, starting from small data sets with high impact on specific care and then gradually expanding toward more comprehensive data sets with an increased emphasis on secondary uses of data.

Highlights

► Successful health IT policy should set clear goals and intended effects of HIT implementation without being overly prescriptive. ► Successful health IT policy should consider an iterative-incremental management approach for infrastructure, data and interoperability standards. ► Successful health IT policy should define frameworks for guiding HIT policy improvement in a continual and systematic manner. ► Successful health IT policy should address issues around meaningful use and legacy health IT systems in use. ► Successful health IT policy should capitalize on the value of clinical and administrative data for secondary uses.

Introduction

Health Information Technology (HIT) provides opportunities to improve patient safety, quality of care and clinical effectiveness [1], while reducing the cost of care [2], [3]. However, even in countries with centralized health systems experiencing notable utilization of information technology such as the U.K., it is challenging to realize the benefit of large and coordinated national HIT investments [4], [5]. The U.S. and Canada have shown lower HIT adoption rates than other Organization for Economic Co-operation and Development (OECD) countries [6]. Both countries have also experienced unprecedented and substantial federal investment with the goal of accelerating adoption and use of HIT [7], [8]. In 2001 Canada created Canada Health Infoway (CHI), an independent federally funded non-for-profit organization, to facilitate development of EHRs and pan-Canadian adoption with an investment of 1.58 billion [8]. Similarly, in the U.S., the Health Information Technology for Economic and Clinical Health (HITECH) Act allocated over $27 billion be distributed over 10 years to promote the adoption and use of HIT in general and EHRs in particular [7]. Canada's efforts, as evaluated at the conclusion of 10 years since the inception of CHI, have brought the country to the point where EHRs are used by 22% of Canadian physicians (as of March 2010) which is well below the target of 50% that CHI had set to reach by the end of 2010 [9].

We examined current U.S. views, as U.S. policy makers take on the task of designing and implementing policies for HIT towards a national health care system. We investigated in turn the challenges and successes of Canada's corresponding national policy experiment, in order to provide insights and improve the prospects for the successful realization of similar initiatives in the U.S. and other countries. In particular, we attempt to identify the aspects of Canadian policy for technical infrastructure, data standards and interoperability that have led to success, as well as any key barriers contributing to low rates of HIT adoption. We also compared the identified barriers and elements of success by Canadian informants to those identified by U.S. informants who face similar challenges.

Section snippets

Design

A qualitative case study approach was used to identify relevant barriers, facilitators and issues on HIT policy development among key stakeholders in Canada and the United States. Using purposive sampling, we selected stakeholders that would represent diverse perspectives and from regions with minimal, moderate and major success in HIT adoption.

Identification of policy domains

In order to set a framework for our interview and focus the interviewers’ responses, we set out to identify the domains that significantly influence the

Results

Overall, a total of 60 interviews were conducted, 29 with Canadian informants and 31 with informants from the U.S. We found that most stakeholders viewed that policy played a key role in HIT in general, enabling and supporting the realization of strategic health goals including improvements in patient health outcomes and the promotion of a care continuum across healthcare settings (Table 1, quotes 1 and 2). The expectation is that these goals would be achieved through the acceleration of EHR

Discussion

While Canadian and U.S. stakeholders had similar views on many attributes that will enable the success or failure of HIT policy initiatives, there were also significant differences. Respondents from both countries agreed that both attainment of a critical mass of EHR adoption and the implementation of interoperability are necessary to enable HIE. In addition, both sets of respondents urged that the definition of standards and data sets for exchange should be guided by measures for health

Limitations

There are several limitations to our study. First, our respondents were selected according to expertise, experience and participation in HIT policy. By selecting respondents from the four (4) groups (national or regional agencies responsible for HIT, quality, safety and research institutes, health professional groups, and EHR and health IT vendors) and six (6) regions, we attempted to address respondent bias. The stakeholders that were interviewed, however, did not include patients. Thus, the

Conclusion

We sought to identify lessons learned, areas of concern and barriers to the development of effective policies around technical infrastructure, data standards, and interoperability. Major concerns surrounding the attainment of national interoperability included achieving a critical mass of EHR adoption among clinicians, the development of standards for data exchange to be based on health outcomes, ways of dealing with legacy health systems and policies, proper training for the new systems, the

Author contributions

The following authors have contributed as follows:

Authors involved in the conception and design of the study, or acquisition of data, or analysis and interpretation of data include all listed authors: Claudia A. Salzberg, Yeona Jang, Ronen Rozenblum, Eyal Zimlichman, Robyn Tamblyn and David W. Bates.

Authors involved in the drafting of the article or revising it critically for important intellectual content include Claudia A. Salzberg, Yeona Jang, Robyn Tamblyn and David W. Bates.

Authors

Conflict of interest

There are no conflicts of interest.

Funding

This study was supported by the Commonwealth Fund (grant no. 20100011) and the Canadian Institutes of Health Research (grant no. ETG-92251).

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