Part 2

Money talks.

In other words, offering financial incentives is one way to effect behavior change.  It seems to have worked in getting providers to adopt and use health IT in everyday practice, both in New Jersey and nationally.

HITECH and Meaningful Use Incentive Payments

As explained by ONC in its October 2014 “Report to Congress”:

“Prior to the HITECH Act, adoption of EHRs among physicians and hospitals was quite low. In 2009, roughly one-half (48 percent) of office-based physicians had any type of EHR system. When examining the adoption of EHRs containing functionalities, such as the ability to generate a comprehensive list of patients’ medications and allergies and the ability to view laboratory or imaging results electronically, only 22 percent of office-based physicians had a basic EHR system. U.S. hospitals had similar adoption rates. In 2009, only 12 percent of hospitals had adopted a basic EHR system.”

Stethoscope and currency
Copyright: / 123RF Stock Photo

According to ONC, as of June of 2014, more than 75% of the nation’s eligible physicians had received incentive payments, while 92% of eligible hospitals (including critical access hospitals) had received incentive payments. The areas evaluated by CSHP covered key meaningful use criteria eligible physicians must meet in order to receive these payments.

For the NJ evaluation, CSHP conducted and analyzed a physician mail survey, clinical laboratory and pharmacy mail surveys with telephone follow-up, and physician follow-up telephone interviews with fax and mail follow-up.  In addition, Health Information Organization (HIO) use metrics from each of New Jersey’s six regional HIOs were collected from the New Jersey Department of Health and analyzed by CSHP researchers.

New Jersey Health IT Adoption

The CSHP Report findings identified several key themes.  Among physicians responding, older physicians, those in smaller practices, and specialists were less likely to adopt health IT and more likely to report barriers to adoption (particularly start-up and maintenance costs) and were also more likely to report implementation of health IT as having had a negative impact on their practices.

Most physicians who reported use of health IT felt that use of health IT had a positive impact.  However, they frequently cited start-up and maintenance costs cited as barriers to health IT use.  For labs and pharmacies, those not using health IT reported more perceived barriers to health IT use and anticipated a more negative impact on their workflow and productivity.  Among physicians, labs, and pharmacies, the lack of uniform standards within the industry was cited as resulting in poor system compatibility and was a major issue across all types of health IT.

CSHP weighted the physician mail survey data by specialty to be representative of New Jersey’s office-based physicians. Key findings regarding specific health IT use among the state’s physicians responding to the physician mail survey included the following:

  • Nearly three-fourths (72.5%) of physicians reported use of health IT to transmit prescriptions to pharmacies electronically.
  • Nearly two-thirds (62.6%) of physicians reported use of health IT to view test results from clinical labs electronically. However, only 37.1% reported use of health IT to send lab test requests electronically.
  • Nearly half (48.9%) of physicians reported that they maintained 100% of patient records in their EHR systems.
  • More than half of physicians (57.3%) provided a clinical visit summary to at least 50% of their patients. Less than half of physicians (42.9%) provided electronic patient care summaries to other providers. About one-quarter of physicians (23.0%) accessed electronic patient care summaries created by other providers.

In (very general) comparison, the ONC Report found that in 2013, 57% of prescriptions sent by physicians were sent electronically.  ONC also reported that more than two-thirds (69%) of physicians reported having the capability to order lab tests electronically, while more than three-quarters (77%) reported having the ability to view the lab results electronically.

Perhaps statewide health IT interoperability through expansion of and connection among regional NJ HIOs can be achieved in the next decade, but it will require creation of the necessary health IT infrastructure, awareness of its existence by the providers who will use it, and, perhaps, financial or other incentives to effect its adoption and use.


When I need to travel from the southern part of NJ to northern NJ, I often rely on my car or phone GPS and the relative ease and simplicity of the NJ Turnpike.  If I needed my southern NJ physician to share information with my northern NJ physician, I might be surprised to learn that it’s not as easy to get my health data from point A to point B.  My physicians might be using electronic health records (EHR) and health IT, but the communications infrastructure in NJ needs to be further developed.  We need greater awareness and adoption of regional health information organizations (HIOs), a way to fund their maintenance (an EZ Pass system for the transmission of health data?), and development of a connected, statewide system.

In January of 2011, the Office of the National Coordinator for Health Information Technology (ONC) awarded New Jersey $11.4 million to be used for developing a strategic and operational plan for health information exchange, and required the state to conduct an independent evaluation of the state’s health IT program.  The Rutgers University Center for State Health Policy (CSHP) conducted the evaluation and published a Report (Brownlee, et al) last year showing where New Jersey physicians stand (or stood, during a survey period that ran from late 2013 to early 2014) in terms of adoption and use of health IT.

NJ Physician Engagement with Regional HIOs - Pie ChartWhen I read the Report, I was surprised to see that while physician use of health IT is increasing, the road to regional health data sharing (let alone statewide sharing) seems to be a long way off.  The Report found that awareness of the existence of a regional HIO by physicians was low (12.5%), and physician participation in a regional HIO was even lower (6.8%). The New Jersey Turnpike is gloriously accessible and functional as compared with this glimpse of the New Jersey health IT highway.

Where Are We Now? to be continued…

The Secretary of Health and Human Services (HHS) released today a compendium of reports on state law, business practices, and policy variations to assist health information exchange efforts.  I reviewed some of the documents linked through HHS’s e-mail and find it extremely helpful that the government is aggregating resources on its website to be used by all in their HIE and RHIO efforts.  The links and summaries of each such report provided through HHS’ s e-mail are reprinted here below:

  • Report on State Medical Record Access Laws This report analyzes state laws that are intended to require health care providers (specifically, medical doctors and hospitals) to afford individuals access to their own health information and to identify potential barriers to the electronic exchange of health information.  Specific state law provisions examined: scope of medical records to which patients are afforded access, format of information furnished, deadlines for responding to requests, fees for furnishing copies, record retention laws and access to records of minors.
  • Report on State Law Requirements for Patient Permission to Disclose Health Information
    In Phase I of the HISPC project a majority of participants reported significant variation in the business practices and policies surrounding the need for and process of obtaining patient permission to use and disclose personal health information for a variety of purposes, including for treatment. This report furthers the initial work of this project by collating and analyzing state laws that govern the disclosure of identifiable health information for treatment purposes to identify commonalities and differences.


  • Releasing Clinical Laboratory Test Results: Report on Survey of State Laws For this report, state statutes and regulations were analyzed to determine to whom clinical laboratories may release test results. This report focused on clinical laboratory and hospital licensing laws (that contain standards for hospital laboratories). It also examined general state medical record access laws to determine whether they provided an avenue for patients to access their clinical laboratory results directly.  

  • Report on State Prescribing Laws: Implications for e-Prescribing This report identifies and analyzes the impact and variation of state laws related to e-prescribing.  The report addresses state laws related to the e-prescribing of controlled and non-controlled substances as well as topics such as record keeping and content requirements, out-of-state prescriptions, and generic substitution laws.

  • Perspectives on Patient Matching: Approaches, Findings, and Challenges This report analyzes various approaches to matching patients to their health information in the context of electronic health information exchange.  Current and potential methods for matching patients to their health records are discussed, challenges to performing patient matching such as scalability and ease of use are analyzed, and the types of information some HIOs use to match patients to their health records is described.

The National Health Information Network (NHIN) may get information moving as early as the first quarter of 2009.  In its December 16th Press Release, the Social Security Administration (SSA) indicates that it will begin receiving medical records for some disability applicants via the "MedVirginia" health information exchange (HIE) based in Richmond.  

SSA and MedVirginia were also among several federal agencies and HIEs that participated in demonstrations of the national network during the 3rd annual NHIN Forum in Washington D.C., which took place this December 15-16.  Other federal agencies that are participating in the NHIN Trial Implementation include Centers for Disease Control (CDC), Veterans Administration (VA), Department of Defense (DOD) and Indian Health Service.  There are also several other state HIEs that are actively participating in the NHIN Trial Implementation, including HIE networks from Indiana, North Carolina, Ohio, Delaware, West Virginia. 

As I’ve posted before, New Jersey is actively working on developing its own state-wide HIE.  The New Jersey Health Information Technology (NJ HIT) Commission is charged with approving the plan for the creation of an infrastructure to move health information, in a confidential and secure manner, among participants in a state-wide RHIO.  On December 4, 2008, I participated in the first meeting of the NJ HIT Commission, which was both inspiring and daunting at the same time, with respect to the road that lies ahead.  Yet, I look forward to working together with the other Commission members during a time of potentially revolutionary changes to health care delivery in this State, and nationally.

The Department of Health and Human Services (HHS), Office for Civil Rights (OCR) has published a new HIPAA Privacy Rule guidance as part of its "Privacy and Security Toolkit" (the "Toolkit") developed in connection with "The Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable Health Information" (the "HIE Framework").  The new HIPAA guidance is available on the OCR Privacy Rule web site.

The federal government developed the HIE Framework and Toolkit in order to establish privacy and security principles for health care stakeholders engaged in electronic health information exchange ("e-HIE").  The documents also include tools to help implement these principles. Among other things, the new HIPAA Privacy Rule guidance document discusses how the Privacy Rule supports and can facilitate e-HIE in a networked environment.  In addition, the documents address electronic access by patients to his/her PHI, and how the Privacy Rule applies to and supports the use of Personal Health Records.



On June 12, 2008 at the Government Health IT Conference & Exhibition in Washington D.C., Microsoft released version 2 of its Connected Health and Human Services Framework, which it touted as providing a "flexible, individual and family-centered approach for addressing the challenges that face HHS agencies, departments and programs as they respond to complex social needs and problems and deliver services to individuals and families in need."

Health Data Management notes that Microsoft has been working with numerous HHS state and federal agencies, and noticed the need for a connected HHS framework that links people, information, systems and devices to help expand access to care, improve quality of services and outcomes, and help protect the safety and well-being of clients and the community. 

Eventually, if nationwide HIE becomes a reality, then public sector agencies also need to be technologically linked-in and ready to receive and send information electronically.  Many licensed facilities and providers are obligated under either state or federal reporting laws to transmit certain health information to agencies for monitoring and tracking of public health issues.  Such releases are not prohibited under HIPAA under either the "public health" disclosure exception, or because they are "required by law."

The National Alliance for Health Information Technology released its final Report to the Office of the National Coordinator for Health Information Technology (aka "ONC") today which, among other things, provides consensus definitions for the following six key health information technology terms:

  • Electronic Medical Record (EMR)
  • Electronic Health Record (EHR)
  • Personal Health Record (PHR)
  • Health Information Exchange (HIE)
  • Health Information Organization (HIO)
  • Regional Health Information Organization (RHIO)

The project which resulted in the Report was called "Defining Key Health Information Technology Terms" and was funded by ONC with the goal of addressing the need to clarify terminology used in health IT policy, regulation, contracts and other initiatives.  The Report, which also includes helpful explanations, guidance, statistics, and links to a number of other helpful resources, is an must-see for all individuals, groups or organizations engaging in HIE and/or looking to form an HIO or RHIO . . .  as such terms are defined in the Report, of course.

On May 13th, the Office of the Governor announced several direct appointments to the New Jersey Health Information Technology (NJ-HIT) Commission, and I am extremely pleased to pass along that I have been appointed to the attorney seat on the Commission.  I look forward to bringing my experience and enthusiasm to the table, and contributing to the success of the Commission’s goals.

The NJ-HIT Commission was created by the New Jersey Health Information Technology Promotion Act, and its members, with the assistance of the Department of Banking and Insurance, are charged with developing, implementing and overseeing the establishment and creation of a state-wide health information technology plan utilizing electronic medical records.  Among other things, the Commission will be looking to the national standards for the State’s HIT system for security, privacy, data content, format, vocabulary and information transfer standards.

The Commission will ultimately include over 19 members of the public, including representatives from professional health care organizations from across the State.

In 1994, Thomas Edison State College released a health care information networks and technology study that showed that New Jersey could save as much as $760 million by migrating from paper-based systems to an electronic network.

Axolotl Corp. of San Jose, California, has been chosen to implement the Interboro Regional Health Information Exchange in order to facilitate data exchange among providers in the Queens area of New York City. The RHIO will use Axolotl’s Elysium Community Virtual Health Record and EMR-Lite applications to enable participating physicians to access patient lab reports, radiology reports, medication history, allergies and other clinical data via a secure Web application. The RHIO will also use use Axolotl’s Patient Index to ensure correct identification of all patients. 

Elmhurst Hospital Center and Queens Hospital Center are spearheading the development of the RHIO. Other participating organizations are New York Hospital Queens, Woodhull Medical and Mental Health Center, HHC Health and Home Care center and several payers.

The Agency for Healthcare Research and Quality has released a series of reports funded by AHRQ and the Office of the National Coordinator for Health IT which examine the variations in data privacy and security among 34 regional health information organizations.  The reports found that state RHIOs varied in several areas, including the level of adoption for electronic health data exchanges, state health care market forces, and legal and regulatory conditions related to health information.   According to Health Data Management, the reports also recommend additional research and guidance on:

  • Determining states’ varying interpretations of HIPAA
  • Assessing differences between state and federal privacy laws 
  • Assessing technologies that could protect the security and privacy of individuals, as well as the related administrative processes and liabilities
  • Creating a system that matches patients with their health information and is updated by various providers and organizations, and
  • Developing a standard set of definitions and terms to ease health data sharing