Summary

Although electronic sharing of medical data is crucial to the effective and efficient delivery of quality health care, more than a decade of effort has yielded little agreement among public and private interests on the standards required to develop an automated medical records system. As a result, U.S. health care practitioners continue to rely on a cumbersome, paper-based clinical records system that has remained largely unchanged for decades. Efforts to develop automated medical record standards have been stymied by a lack of leadership. Several voluntary organizations have been most active in developing standards. But the complex nature of medical care, the large number of standards needed, and the variety of special interests involved in standards development have made this a daunting task. To date, the federal role in this effort has been limited. GAO believes that more active federal involvement could speed standards development.

GAO found that: (1) standards are crucial to sharing automated medical records due to the complex nature of modern health care and the need for a high degree of security and confidentiality; (2) vocabulary, structure and content, messaging, and security standards are needed for the effective exchange of medical information; (3) the health care community has developed only limited standards over the last 10 years, with the greatest progress in messaging standards; (4) the health care community has formed the Health Care Informatics Standards Planning Panel (HISPP) to coordinate standards development activities; (5) the lack of leadership to establish priorities, marshal resources, coordinate activities, and facilitate consensus-building has hindered standards development; (6) the federal government has played a minimal role in developing automated records standards because it relies on voluntary standards development organizations where feasible; (7) the Agency for Health Care Policy and Research (AHCPR) has the responsibility for developing automated medical records standards, but is reluctant to take its leadership role in the development process; (8) AHCPR has sponsored meetings on linking public and private medical data, funded research, and provided organizational support to HISPP; (9) other federal agencies that use medical records have participated in standards development with voluntary organizations in order to provide input on their mission needs; and (10) the Health Care Financing Administration has helped draft legislation that addresses its needs, sets standards priorities, sets target dates for certain standards to be in place, and requires hospitals to submit data electronically.