State Policy Reflects Emphasis on HIT
The number of policy changes and mandates within states is a key indicator of the recognition by state leaders that HIT can play a key role in improving healthcare. Since 2006, there has been a nearly two-fold increase in state legislation proposed relating to health information technology (HIT). These bills increasingly represent a general trend towards greater linkage between improving healthcare quality and health IT. State legislation also reflects a more sophisticated understanding of technical and interoperability requirements of HIT systems being purchased by the state, as well as strategic plans for statewide implementation.
Despite the progress made by the Department of Health and Human Services (through such entities as the Office of the National Coordinator for Health Information Technology and the federal advisory committee, the American Health Information Community in the fields of standards and privacy protections), a lack of comprehensive action by Congress may be a significant contributing factor to the increase in state-level legislation proposed and passed in 2007.
A number of states are moving forward in parallel with federal efforts to develop and implement policies and plans that promote health IT and health information exchange. While there was virtually no legislation at the state level related to health IT prior to 2005, in 2005 and 2006 thirty-eight states introduced 121 bills specifically focused on health IT, and of those, 36 bills were passed into law in 24 states.1
In 2007 to date, 208 bills have been introduced across all 50 states that refer to the adoption or implementation of health IT on some level, 30 of which have been signed into law in 19 different states.2
Along with the increase in the overall quantity of bills being introduced and passed on the state level, the focus of these bills has shifted over time. State legislation is increasingly calling for a focus on improving the quality of care through the use of health IT, rather than focusing on health IT implementation alone. Several of these bills also authorize funding of state initiatives, or establish exploratory and investigative task forces to facilitate state progress.
U.S. governors are also playing a critical role in moving forward. In 2007, nine separate executive orders have been issued which are designed to drive improvements in health and healthcare through the use of health IT.3
State Legislative Priorities
- Addressing Healthcare Costs: States continue to face a need for fiscal stability in the wake of an uncertain national economic environment. As such, many states have pursued legislative tracks focused on reducing overall state costs through the use of comprehensive HIT systems. State leaders have remained vigilant in their emphasis of these systems to drive down overall state costs and increase revenue through future health savings.
- Building Capacity Statewide: In 2007, at the time of this report, 30 separate pieces of legislation have been passed in 19 different states which focus on building the capacity for health IT. Many of these, including in the state of Connecticut, Indiana, Maine, Maryland, Pennsylvania, Vermont and Washington have passed legislation that applies to the electronic exchange of health information on a statewide basis. Some legislation has created a statewide entity (Indiana), while others focus on standards (Connecticut).
For example, the state of Indiana passed legislation which established the Indiana Health Informatics Corporation, “for the purpose of ensuring and improving the health of the citizens of Indiana by encouraging, facilitating, and assisting in the development and operation of a statewide system for the electronic exchange of health care information and other health informatics functions in Indiana.”4 This move by the State of Indiana, similar to a bill that passed in Texas, could be a sign of the significant progress that states like Indiana have made recently in the field of health information exchange.
The state of Connecticut passed legislation authorizing the Department of Public Health to “develop electronic data standards to facilitate the development of a state-wide, integrated electronic health information system for use by health care providers and institutions that are funded by the state.” Such standards, under the law, must be compatible with any national data standards and “be compatible with the requirements for an electronic health information system.”
- Supporting Planning and Progress: Many states also continue to codify initiatives designed to investigate the process by which statewide health information network should be developed. Fifty-seven bills have been proposed in 2007 that call for the establishment of a committee, taskforce, commission or working group.
These planning entities are typically composed of diverse members, and the specific goals of the entities vary across the states. Vermont, for example, passed H.531 on June 5th, 2007 which called for the development and implementation of a Blueprint for Health, including a five year plan that must further the use of information technology. Texas, on the other hand considered a bill in January of 2007 that sought to establish an “Electronic Health Information Coordinating Committee,” which was designed to consult with practicing physicians and others to develop recommendations concerning the proper alignment of financial incentives to increase physician use of EHR systems.5 This bill has not been passed into law.
Another piece of legislation enacted in the state of Colorado created a Health Information Technology Advisory Committee tasked with creating a long-range plan, on or before January 1, 2009 for health IT including the use of EHRs, clinical decision support systems and regional data sharing agreements. This law goes even further by requiring the committee to “pursue an interstate compact between (but not limited to): Arizona, Kansas, Montana, Oklahoma, New Mexico, North Dakota, South Dakota, Utah, and Wyoming, to create internal state HIT and HIE programs with the goal of connecting and exchanging information.”6 While this is a clear indication of Colorado’s future plans to connect across state lines, certain neighboring states, aside from telemedicine infrastructure plans, have very little policy written concerning intrastate or interstate HIE.
Another commission established under law in 2007 in the state of Idaho is responsible for providing leadership for the development and implementation of an interoperable HIT infrastructure by awarding performance study contracts as well as creating a plan for developing a uniform, statewide interoperable HIT system.
These three different examples of task forces and committees stand as examples of the evolution of these entities from past legislation that was proposed and passed in states. Nearly all of these committee proposals include provisions stressing the need for quality studies and improvement strategies. Increasingly, sustainability is also stressed in the development of comprehensive statewide HIT planning.
- Interoperability: States have also begun to dictate certain interoperability levels in proposed state legislation, insofar as such legislation affects state agencies. These bills range in their directives from basic bureaucratic processes for the State’s purchasing of HIT systems, to more detailed levels of interoperability that must be present in a an EHR system purchased with state funding.
In addition to the standards and interoperability-related bill passed this year by the state of Connecticut as described above, a bill proposed in Texas, for example, calls upon all EHR vendors who “sell, lease, or otherwise provide an electronic medical records software package or system to a person who administers immunizations in this state or to an entity that manages records for the person shall provide, as part of the electronic medical records software package or system, the ability to: (1) electronically interface with the immunization registry created [previously in the bill] and (2) generate electronic reports that contain the fields necessary to populate the immunization registry.”7 This type of bill, one that requires an EHR system to interoperate with a separate HIT system such as an immunization registry, is more prevalent in state legislation than has been seen in previous years.
State Statistics Overview: 2005-2007
|
Proposed: 2005-2006 |
Proposed: 2007 |
Passed: 2005-2006 |
Passed: 2007 |
Number of States |
38 |
50 |
24 |
30 |
Number of Bills |
121 |
208 |
36 |
19 |
Focus of Legislation:
- 57 bills refer specifically to creating a committee, task force or work group designed to study implementation scenarios of greater HIT utilization.
- 38 bills refer to utilizing HIT to improve the quality of care or quality of data reporting, 36 of which refer directly to the use of an EHR for the purposes of improving care.
- 82 bills include direct funding appropriations and/or loan programs or tax credits for the purchasing of various HIT tools (EHR systems, electronic public health surveillance reporting systems, etc…)
- 14 bills include some form of mandate authorization or mandate for the use of ePrescribing
U.S. Governors Driving Change at the State Level
State legislatures are not the only policymakers driving change in states. Governors across the nation are increasingly recognizing the value of health IT in addressing their healthcare goals and issuing executive orders to drive change. As of the date of this report, 9 U.S. Governors have issued executive orders designed to drive improvements in health and healthcare through the use of health IT in 2007.
By and large, the majority of 2007 gubernatorial executive orders focus on the creation of commissions, committees, advisory boards and taskforces to make recommendations to the State regarding health IT, quality and cost.
2007 Executive Orders Issued by State Governors
State |
Date Issued |
Governor |
Description |
California |
March 14th, 2007 |
Schwarzenegger |
Convenes the California eHealth Action Forum to devise financing strategies to allocate at least $200 million in investment funds and $40 million in grant monies and oversee the implementation of a mix of public/private financing alternatives to facilitate the rapid adoption and sustainability of HIT in the state. |
Maryland |
October 27, 2007 |
O’Malley |
Establishes a Health Quality and Cost Council to be chaired by the Lieutenant Governor. The council will have, among other duties, the responsibility to facilitate the integration of health IT into healthcare systems. A request for planning and assistance is likely to be issued by the end of 2007. |
Ohio |
September 15, 2007 |
Strickland |
Creates an advisory board aimed at reducing the growth in healthcare costs by improving the exchange of health information between providers and patients. The board will bring together representatives from the public and private sectors to work on health information technology issues which can lower healthcare costs and provide higher quality and more patient-oriented care. |
Virginia |
September 10, 2007 |
Kaine |
Ordering the creation of a council to encourage the public-private partnerships in increase adoption of electronic medical records for physicians. The council will also be required to identify areas where HIT can lower costs for the State of Virginia. A final report is due to the Governor by May 15, 2008. |
Mississippi |
March 7, 2007 |
Barbour |
Recognizes that a statewide HIT infrastructure would improve the quality and reduce the cost of health care in Mississippi. It calls for the creation of the twenty member Mississippi Health Information Infrastructure Task Force to review issues surrounding the creation of a statewide and inter-state HIT infrastructure to improve the quality and safety of health care delivery in Mississippi. The Task Force shall develop recommendations related to the overall use of HIT and HIE. |
Missouri |
March 2, 2007 |
Blunt |
Recognizes the potential of HIT to improve patient safety and healthcare quality by reducing medical errors and adverse drug events, reducing healthcare costs, and improving access to underserved areas. It establishes the Missouri Healthcare Information Technology Task Force to meet and make initial recommendations to the Governor by July 1, 2006. |
Georgia |
February 12, 2007 |
Perdue |
Building on the 2006 creation of the Health Information and Transparency Advisory Board, this order calls for the state to encourage health care providers, health insurance plans, and third party administrators to utilize HIT systems. Also calls for the state to examine appropriate opportunities to promote pay for performance in healthcare financing and empowerment for patients to use information on the quality and cost of care in making healthcare decisions. |
Kansas |
February 8, 2007 |
Sebelius |
Creates the multi-stakeholder Kansas Health Information Exchange Commission, which shall: promote the public good by ensuring an equitable and ethical approach to HIE for the improvement of health care; encourage collaboration and facilitate a standardized approach to interoperable HIE in Kansas; recommend policy that will advance HIE in Kansas while protecting the privacy and security of citizens' private health information; and leverage existing HIE initiatives in Kansas. |
Washington |
January 3, 2007 |
Gregoire |
Recommits making Washington State a leader in the way it buys and uses health care including: making better use of information technology based on legislation passed in 2005, which sets a statewide goal to have all hospitals, integrated delivery systems, and providers adopt HIT by 2012. |
eHealth Initiative, States Getting Connected: State Policy Makers Drive Improvements in Healthcare Quality and Safety Through IT. Washington, D.C.: eHealth Initiative; August 2006.
eHI State Legislation Tracker. www.ehealthinitiative.org. Accessed October 2007.
State of Indiana, SB0551. Indiana Health Informatics Corporation. May 2, 2007.
State of Texas, SB 40. Electronic Health Information Coordinating Committee. January 23, 2007.
