AMERICAN HOSPITAL ASSOCIATION
J
ry 2012
FEBRUARY
2016
TrendWaTch
Bringing Advance
Behavioral
Health into
the Care
Hospitals
Information
Sharing,
but Continuum:
External Barriers to
Opportunities
ImproveRemain
Quality, Costs and Outcomes
Increased
Data to
Exchange
H
O
ospitals
are adopting
health
and
streamlining
administrative
ne in four
Americans
experiences
intense
alterations
in thinking,processes.
mood
information
technology
(IT) toabuse Patients
also benefit
bytime.
gaining
easier,
a mental illness
or substance
and/or behavior
over
Substance
enable
providers
to capture
securely
automated
accessare
to their
health resulting
data.
disorder
each year,
and theand
majority
also
abuse disorders
conditions
transmit
and receive
patient
care condiand
Hospitals
are proactively
has a comorbid
physical
health
from
the inappropriate
usedeveloping
of alcohol,
health
Thismore
information
supports
the
means to share
between
tion.1 data.
prescription
drugsinformation
and/or illegal
drugs.4
In 2009,
than 2 million
clinicians
making
more informed
departments
as welldisorders
as with other
dischargesinfrom
community
hospitals
Behavioral health
may care
also
decisions
the pointdiagnosis
of care and
increases
partners,
public health
were for at
a primary
of mental
include apatients
range ofand
addictive
behaviors,
efficiency
eliminating
redundant
tests
agencies.
While access
to datadisorders,
has
illness or by
substance
abuse
disorder.2,3
such as gambling
or eating
characterized by an inability to abstain
The range of effective treatment
from the behavior and a lack of awareoptions for behavioral health disorof the problem.5
ders—which encompass both mental
Recent Data Show that Hospitalsnessare
Improving Their Ability to
illness and substance abuse disorders—
Health reform creates new impetus
is expanding.
Research
indicates
that
and opportunity
for better
managing
Information
sharing
is critical
to support
capabilities
to support
information
better
integration
of
behavioral
health
the
care
delivered
to
individuals
providers in their efforts to improve
sharing. Hospitals have increased with
the
care
services
into
the
broader
health
these conditions.
of health
quality, engage patients, advance
ability
to send andExpansion
receive clinical
care
care continuum
a positive
insurance generally,
alongEHRs
with (Chart
improved
population
health can
and have
reduce
costs. Care
information
through their
1).
impact
on
quality,
costs
and
outcomes.
coverage
of
behavioral
health
treatment
models that strive to coordinate care
Between 2011 and 2014, during Stage 1
Mental
illnesses are
diagnosunder parity laws, will broaden access
across
the continuum
forspecific,
an episode
or
able
disorders.
Each
is
characterized
by
to needed services. At the same time,
patient population, such as accountable
care organizations and bundled payments,
rely on access to an up to date record of
a patient’s condition and history of care.
Highly Prevalent, Behavioral
Hospitals have invested substantially in
Economic
and Social
Impact
health
IT and electronic
health records
(EHRs), with a goal to increase their
Behavioral health disorders affect a subcapacity for sharing data electronically
stantial portion of the U.S. population.
with patients and care partners. Through
Nearly half of all Americans will develop
the Medicare and Medicaid EHR
a mental illness during their lifetime.6 An
Incentive Program, U.S. hospitals have
estimated 22.5 million Americans sufbeen eligible for financial incentives for
fered with substance abuse or dependence
adopting 7and using EHRs in accordance
in 2009, and 27 percent of Americans
with federal meaningful-use criteria.
will suffer from a substance abuse disorResults from the AHA’s Annual Survey
Information Technology Supplement
provide insights into hospitals’ current
increased, provider
critical infrastructure
and
increased
accountability
will
technical
barriers
constraincare
the across
sharing of
spur
efforts
to coordinate
patient information
settings
of care.
currently
fragmentedacross
settings
to improve
As aefficiency
result, information
sharing of
requires
the
and effectiveness
care
significanttowork
and expense.
Between
delivered
individuals
with behavioral
2010 and
2014, hospitals collectively
health
conditions.
spent
hundreds
of billions
dollars
on
Many
providers
alreadyofare
worktheirwith
IT systems.
ing
private 1payers to meet these
same goals. Initiatives span value-based
purchasing, accountable care organizations, patient-centered medical homes,
Share Information
and efforts to reduce readmissions.
These
will
have
important
and theinitiatives
first year of
stage
2 of
the EHR
implications
for
the
delivery
of behavIncentive Program, hospital information
ioral
health
care.
And
as
the
demand
sharing in both inpatient and ambulatory
for
health
services
is likely
carebehavioral
settings with
providers
outside
theto
continue
to outstrip
capacity,
improvhospital’s system
improved
markedly.
ing care integration can help to better
manage this need.
Hospitals show marked improvement in information exchange with
care partners outside their system.
Chart Disorders
1: Percent of Hospitals
Electronically Exchange Clinical/Summary of Care
Health
Have that
a Significant
Record in any Format, 2011 versus 2014
■ 2011
■ 2014
77%
73%their
72%
used behavioral health services in a year.11
der during
lifetimes.8 While
71% behavioral health disorders primarily affect
The economic and social 60%
costs associ57%
adults, they also are prevalent among
ated with behavioral health are significant,
children. Among children, mental health
underscoring the importance
of treating
37%
conditions were the fourth most common
these conditions.12 In the majority of
22%behavioral health conditions are
reason for admission to the hospital in
cases,
9
2009. Studies reveal that approximately
serious enough to cause limitations in
daily living and social activities.13 For
17 percent of Medicare beneficiaries have
a mentalHospitals
illness.10in An analysis
example,
behavioral health
conditions
of Medicaid
Ambulatory
care
Hospitals outside
Ambulatory
care
your system
providers in your
of your system
providers outside
hinder
worker
productivity
and
raise
beneficiaries across 13 states found
that
system
of your system
absenteeism,
resulting
in
reduced
income
more
than
11
percent
of
beneficiaries
Source: AHA analysis of AHA Annual Survey IT Supplement data, 2011 and 2014, for community hospitals.
HOSPITALS ADVANCE INFORMATION SHARING, BUT EXTERNAL BARRIERS TO INCREASED DATA EXCHANGE REMAIN
Hospitals increasingly share a
summary of care with other care providers
when a patient is discharged. There
are multiple methods for sending data
electronically, and a hospital may use
one or more methods on a routine basis
(Chart 2). Sharing patient information
during transitions in care is an essential
aspect of ensuring care is coordinated and
limiting redundancy in testing. However,
the standard information currently
included in summary of care documents
that are required in the EHR Incentive
Program often does not meet the needs of
clinicians. As a result, hospitals must rely
on custom programming and additional
configurations in order to ensure
sufficient patient information is shared
for care decisions. With the appropriate
standards in place, providers could obtain
the data they need without additional
work-around solutions.
Hospitals also are participating in
health information exchanges (HIEs).
HIEs facilitate health data exchange and
serve to aggregate and make available
data about a patient’s previous care to
Patients’ Online Access to
Health Data is Growing
Patients have gained widespread online
access to their hospital medical records
over the past few years. Eighty-nine
percent of hospitals provided patients
the ability to view information from
their medical record online in 2014,
up from 43 percent in 2013 (Chart 3).
A growing percentage of hospitals also
are offering the option for patients to
perform functions outside of reviewing
their medical record, such as requesting
prescription refills and scheduling
appointments.
Hospitals employ multiple means to share summary of care records
with care partners.
Chart 2: Percent of Hospitals that Routinely Send a Summary of Care Record
Through Indicated Channel, 2014
87%
Secure messaging
82%
eFax using EHR
Health information
exchange
78%
Provider online
portal
70%
Source: AHA analysis of AHA Annual Survey IT Supplement data, 2014, for community hospitals.
clinicians at the point of care. In areas
where HIEs are operational, 75 percent of
hospitals participate. This is a significant
increase over reported participation in
2011, when 22 percent of hospitals were
active in an HIE. Fourteen percent of
hospitals operate in a region not served by
a HIE.2
Hospitals may participate in multiple
HIEs; however, the costs to participate
in a HIE vary and may be substantial. At
the same time, HIEs do not necessarily
support all of the information sharing
that hospitals want to do. In addition,
they may not share information with
other HIEs and there is not a national
HIE network that ensures patient data is
available across providers and localities.
Hospitals have greatly increased patients’ online access to their
health information.
Chart 3: Percent of Hospitals where Patients are Able to Perform the Indicated Services
Online, 2013 and 2014
89%
80%
71%
■ 2013
■ 2014
66%
65%
56%
43%
30%
43%
35%
30%
40%
13%
View
information
from medical
record
Download
information
from medical
record
Request
change to
medical record
Pay bills
Transmit
data to 3rd
party
Request refills for
Schedule
prescriptions
appointments
Source: AHA analysis of AHA Annual Survey IT Supplement data, 2013 - 2014, for community hospitals.
2
31%
TRENDWATCH
Despite Progress, Critical Barriers Still Impede the Effective Flow of Information
Despite significant hospital investment in
IT infrastructure and EHRs, barriers to
information sharing still exist. The lack of
compatibility of products across vendors
makes the effective and efficient exchange
of health data needed to provide care an
ongoing challenge. Hospitals also have the
responsibility of ensuring the privacy and
security of sensitive information.
Health care providers have an obligation
to share information needed for care.
Too often, however, systems do not yet
support effective and efficient data sharing.
Policymakers have recently expressed
concerns around “information blocking” –
the intentional interference with the sharing
of electronic health information. According
to the Office of the National Coordinator
(ONC) for Health IT, most complaints
of information blocking are directed at
vendors and developers, some of whom
charge high fees for users to send or receive
data or for development of the interfaces
necessary to allow two different IT systems
to exchange data. Additional concerns
relative to vendors relate to development
practices that prevent or make it difficult
for EHRs to connect with products and IT
systems made by other companies.3
Because of these and other issues,
barriers to sharing information across
care settings are widespread (Chart 4).
The most prominent barriers are the lack
Hospitals face many barriers to the exchange of information
necessary to efficiently manage patient care.
Chart 4: Percent of Hospitals Reporting Issues when Trying to Electronically Send,
Receive or Find Patient Health Information with Other Care Settings, 2014
Intended recipient does not have an EHR or
other system capable of receiving the data
62%
Other providers have an EHR, but are not
capable of receiving information electronically
60%
Difficult to find provider’s
electronic address
46%
Those receiving summary of care
records do not find them useful
30%
Cumbersome workflow to send
information from EHR system
29%
Extra cost incurred to send/
receive data
28%
Difficult to match or identify
patients between systems
27%
Hospital cannot electronically receive
patient health information
18%
Hospital cannot electronically send
patient health information
Hospital does not typically share
patient data
12%
7%
Source: AHA analysis of AHA Annual Survey IT Supplement data, 2014, for community hospitals.
of EHRs among other care partners or
compatibility between EHR systems. In
addition, directories or other tools to locate
other providers are not widely available.
Further, more than a quarter of hospitals
are required to pay additional costs to send
or receive health data, which provides a
disincentive to information sharing.
Action is Needed to Remove These Barriers
Hospitals have invested heavily in
health IT and EHRs that support the
exchange of health data. Stage 2 of the
EHR Incentive Program increases the
requirements for information sharing,
while Stage 3 rules require use of
standards that are not yet in common
use. Hospitals face significant challenges
in achieving success in either stage
without support to overcome the barriers
to universal information exchange.
Providers need the technology and
infrastructure that will allow their IT
systems to communicate effectively. For
example, providers must often create a
separate interface for each department’s
IT system to allow information to flow
into the hospital’s EHR, even within
the same hospital. The average cost
of a typical interface may range from
$10,000-$20,000, while interfaces
for more complex functions, such as
pharmacy dispensing, may cost as much
as $75,000.4 In addition, a highlyskilled workforce must be deployed to
maintain fragile interfaces. Hospitals
may be required to use hundreds or even
3
TRENDWATCH
TRENDWATCH
thousands of interfaces to share data
across departments and care settings.5
These costs, in addition to selected vendor
Conclusion
practices
such as charging a fee to send
or receive data, make it difficult for
Teaching hospitals provide an environsome hospitals to afford the investments
ment for residents to learn and faculty to
necessary to enable seamless information
serve as educators, providers and researchsharing.
ers. These roles advance the broad mission
Mature, nationally used data and
of teaching hospitals to prepare each
exchange standards for information
generation of physicians, provide critical
exchange are critical for data to flow. Due
patient care and specialized services, often
to a lack of clarity and specificity, vendors
to the disadvantaged; and facilitate the
can interpret and implement standards
discovery of new therapies and treatments.
differently, which makes it difficult and
Congress has long recognized the public’s
expensive to share and integrate data
responsibility to support physician trainacross EHRs.
ing in teaching hospitals, funding DGME
Hospitals are required to purchase
costs since the inception of Medicare
and use EHRs that have been certified
by ONC as meeting all standards and
support the sharing of health data. 2015
was the first year that all providers were
required to use the most recent version
and IME since the introduction of the
of the certified EHR. However, these
inpatient PPS in 1983. While the current
products often fail to operate in an
system offers the predictability necessary
interoperable way, despite certification.
to train tens of thousands of physicians
Vendors must be held accountable for the
each year, residency caps increase the
design and marketing of these products in
risk of physician shortages and threaten
order to ensure hospitals are able to share
patients’ access to care.
data. Additionally, ONC should fix the
The purpose and value of residency
certification program to ensure that EHRs
training in clinical settings and the
are able to support interoperability in a
financial support needed to sustain
real-world environment. Starting in 2015,
physician education will only increase
providers now face financial penalties for
as the U.S. population lives longer
not meeting the information exchange
with more complex health conditions.
and other requirements of the EHR
Incentive Program.
Health information cannot be seen as
belonging to an individual organization.
Improved clinical care will come when the
To ensure GME can meet the future
right information is available to the right
needs of the newly insured and aging
provider at the right time, so that it can
population, policymakers and stakebe used effectively at the point of care and
holders must commit to the consistent
beyond. Hospitals are actively promoting
and current level of GME funding and
the exchange of data, but additional
lift Medicare’s limit on funded residency
technology and infrastructure solutions are
positions. Policymakers must ensure that
needed to ensure that health IT products
payment or policy changes to GME do
are able to readily and easily communicate
not upend a world-class graduate medical
with one another to support the sharing
education system and a financing mechof information critical to ensuring highanism that has achieved the longstanding
quality, efficient care delivery that is
goal of supporting hospitals in the miscoordinated across the continuum.
sion of training physicians.
POLICY QUESTIONS
1. H
ow can health
IT vendors
be encouraged
support
How
policymakers
preserve
the unique to
role
that teaching hospitals
play in education,
research
and
patient
care?
efficient
and effective
information
sharing
across
products?
Physician
educationtoand
training is widely
2. C
an modifications
theclinical
EHR certification
process be
considered
a social
good. support
Should all
payers be required
made
to ensure
products
interoperability
on an
to contribute
ongoing
basis?to ensure the sustainability of graduate
medical education?
3. What governance framework would support more seamless
sharing of health data?
4. W
hatcan
capabilities
are most
essential
patientsefforts
and to
3.
How
policymakers
support
the for
ACGME’s
assure residency
training
programs
meetinthe
needs
the
families
to be able
to accomplish
online
order
to of
engage
21st
centurytohealth
caretheir
delivery
system?
in
activities
improve
health
status and support their
participation
in the
care be
process?
4. What
incentives
should
offered to stimulate medical
interest
choosing
and/
5. students’
Is it reasonable
orin
advisable
toprimary
move tocare
Stagespecialties
3 of the EHR
or
practicing
in underserved
areas?
Incentive
Program
without first
addressing barriers to
information sharing?
ENDNOTES
ENDNOTES
1.
American
Medical
Association.
(5 November
2014).
Requirements
for Becoming
a
1. AHA
analysis
of AHA Annual
Survey data,
2011-2014,
for community
hospitals.
Physician.
2. AHAhttp://www.ama-assn.org/ama/pub/education-careers/becoming-physician.
analysis of 2011-2014 AHA Annual Survey Health IT Supplement data.
page?
3. ONC. 2015 Report to Congress on Health Information Blocking. April 2015.
2. Kirch DG. (29 July 2014). IOM’s Vision of GME Will Not Meet Real-World Patient
4. American Hospital Association. Why Interoperability Matters. October 2015.
Needs.
Association of American Medical Colleges. https://www.aamc.org/newsroom/
5. American Hospital Association. Why Interoperability Matters. October 2015.
newsreleases/381882/07292014.html
3. Accreditation Council for Graduate Medical Education. (6 November 2014). About
ACGME. https://www.acgme.org/acgmeweb/tabid/116/About.aspx
4. Rich EC, et al. (April 2002). Medicare Financing of Graduate Medical Education. Journal
of General Internal Medicine. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495035/
5. Bronnikova O and Cohen J. (17 October 2014). Training the Workforce for a Changing
Health System. Alliance for Health Reform. http://www.allhealth.org/publications/GMEToolkit_160.pdf
6. Association of American Medical Colleges. (2013). Patient Care at AAMC-Member
Teaching Hospitals. https://www.aamc.org/download/379180/data/patientcareone-pager.
pdf
7. Association of American Medical Colleges. (2009). What Roles Do Teaching Hospitals
Fulfill? https://www.aamc.org/download/54360/data/whatrolesdothfulfill.pdf
8. Association of American Medical Colleges. (15 January 2015) AAMC Comments on
the Report of the IOM Committee on Governance and Financing of Graduate Medical
Education. produced by the American Hospital
TrendWatch,
9. Avalere analysis of 2014 American Hospital Association Annual Survey Data.
Association,
highlights important trends in the
10. S. Rep. N. 404, 80th Cong.,1st Sess. 36 (1965); H.R. Rep. No. 213, 89th Cong., 1st
hospital
and(1965).
health care field.
Sees.32
11. Eden J, et al. Institute of Medicine. (July 2014). Graduate Medical Education that
TrendWatch
February
2016
Meets the—
Nation’s
Health
Needs. http://www.iom.edu/Reports/2014/Graduate-MedicalEducation-That-Meets-the-Nations-Health-Needs.aspx
Copyright
© 2016 by the American Hospital Association.
12. Rights
Bronnikova
O and Cohen J. (17 October 2014). Training the Workforce for a Changing
All
Reserved
Health System. Alliance for Health Reform. http://www.allhealth.org/publications/GMEToolkit_160.pdf
13. Paz HL. (November 2011). Funding for Medical Education Under Fire. Penn State Milton
S. Hershey Medical Center College of Medicine. Perspectives. http://www.libraries.psu.
edu/psul/hershey/about/ceo-perspectives/funding-for-medicaleducationunderfire.html
14. Association of American Medical Colleges. (March 2013). Graduate Medical Education.
https://www.aamc.org/download/385618/data/graduatemedicaleducation.pdf
15. Bronnikova O and Cohen J. (17 October 2014). Training the Workforce for a Changing
Health System. Alliance for Health Reform. http://www.allhealth.org/publications/GMEToolkit_160.pdf
16. Association of American Medical Colleges. (2014). What Does Medicare Have to Do with
Graduate Medical Education? https://www.aamc.org/advocacy/campaigns_and_coalitions/
gmefunding/factsheets/253372/medicare-gme.html
17. Association of American Medical Colleges. (2013). Medicaid Graduate Medical
Education Payments: A 50-State Survey 2013.
18. Ibid.
19. Metzler IS, et al. (8 November 2012). The Critical State of Graduate Medical Education
Funding. Bulletin of the American College of Surgeons. http://bulletin.facs.org/2012/11/
critical-state-of-gme-funding/
20. Ibid.
21. Fleming C. (9 September 2014). Rethinking Graduate Medical Education Funding:
An Interview with Gail Wilensky. Health Affairs Blog. http://healthaffairs.org/
blog/2014/09/09/rethinking-graduate-medical-education-funding-an-interview-withAmerican Hospital Association
gail-wilensky/
800 Tenth Street, NW
22. Children’s Hospital Association. (April 2014). The Children’s Hospitals Graduate
Two CityCenter, Suite 400
Medical Education Program (CHGME). http://www.childrenshospitals.net/Content/
ContentFolders34/PublicPolicy/Issues/GME/CHGMEOnePageSummaryApril2014.pdf
Washington, DC 20001-4956
23. Children’s Hospital Association. (11 March 2015). Children’s Hospitals Graduate
202.638.1100
Medical Education Program Overview. https://childrenshospitals.org/issues-and-advocacy/
graduate-medical-education/issue-briefs-and-reports/childrens-hospitals-graduatewww.aha.org
medical-education-program-overview