REPORT TO THE PRESIDENT REALIZING THE FULL POTENTIAL OF HEALTH INFORMATION TECHNOLOGY TO IMPROVE HEALTHCARE FOR AMERICANS: THE PATH FORWARD Executive O!ce of the President President’s Council of Advisors on Science and Technology December 2010 Created: 2:52 PM 09/01/2009 — Modified: 2:27 PM 12/07/2010 REPORT TO THE PRESIDENT REALIZING THE FULL POTENTIAL OF HEALTH INFORMATION TECHNOLOGY TO IMPROVE HEALTHCARE FOR AMERICANS: THE PATH FORWARD Executive O!ce of the President President’s Council of Advisors on Science and Technology December 2010 About the President’s Council of Advisors on Science and Technology The President’s Council of Advisors on Science and Technology (PCAST) is an advisory group of the nation’s leading scientists and engineers, appointed by the President to augment the science and tech- nology advice available to him from inside the White House and from cabinet departments and other Federal agencies. PCAST is consulted about and often makes policy recommendations concerning the full range of issues where understandings from the domains of science, technology, and innovation bear potentially on the policy choices before the President. PCAST is administered by the White House Office of Science and Technology Policy (OSTP). For more information about PCAST, see http://www.whitehouse.gov/ostp/pcast + i + !e President’s Council of Advisors on Science and Technology Co-Chairs John P. Holdren Eric Lander Harold Varmus* Assistant to the President President, Broad Institute of President, Memorial Sloan- forScience and Technology Harvard and MIT Kettering Cancer Center Director, Office of Science and Technology Policy Members Rosina Bierbaum Chad Mirkin Dean, School of Natural Resources and Rathmann Professor, Chemistry, Materials Environment Science and Engineering, Chemical and University of Michigan Biological Engineering and Medicine Director, International Institute of Christine Cassel Nanotechnology President and CEO, American Board of Internal Northwestern University Medicine Mario Molina Christopher Chyba Professor, Chemistry and Biochemistry Professor, Astrophysical Sciences and University of California, San Diego International Affairs Professor, Center for Atmospheric Sciences Director, Program on Science and Global Security Scripps Institution of Oceanography Princeton University Director, Mario Molina Center for Energy and S. James Gates, Jr. Environment, Mexico City John S. Toll Professor of Physics Ernest J. Moniz Director, Center for String and Particle Theory Cecil and Ida Green Professor of Physics and University of Maryland Engineering Systems Shirley Ann Jackson Director, MIT’s Energy Initiative President, Rensselaer Polytechnic Institute Massachusetts Institute of Technology Richard C. Levin Craig Mundie President Chief Research and Strategy Officer Yale University Microsoft Corporation * Dr. Varmus resigned from PCAST on July 9, 2010 and subsequently became Director of the National Cancer Institute (NCI). + iii + Ed Penhoet Daniel Schrag Director, Alta Partners Sturgis Hooper Professor of Geology Professor Emeritus of Biochemistry Professor, Environmental Science and and of Public Health Engineering University of California, Berkeley Director, Harvard University-wide Center for Environment William Press Harvard University Raymer Professor in Computer Science and Integrative Biology David E. Shaw University of Texas at Austin Chief Scientist, D.E. Shaw Research Senior Research Fellow, Center for Maxine Savitz Computational Biology and Bioinformatics Vice President Columbia University National Academy of Engineering Ahmed Zewail Barbara Schaal Linus Pauling Professor of Chemistry and Physics Chilton Professor of Biology Director, Physical Biology Center Washington University California Institute of Technology Vice President, National Academy of Sciences Eric Schmidt Chairman and CEO Google, Inc. Staff Deborah Stine Mary Maxon Gera Jochum Executive Director, PCAST Deputy Executive Director, Policy Analyst PCAST + iv + EXECUTIVE OFFICE OF THE PRESIDENT PRESIDENT’S COUNCIL OF ADVISORS ON SCIENCE AND TECHNOLOGY WASHINGTON, D.C. 20502 President Barack Obama The White House Washington, DC 20502 Dear Mr. President, We are pleased to send you this report, Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward, prepared by your President’s Council of Advisors on Science and Technology (PCAST). This report examines how health information technology could improve the quality of healthcare and reduce its cost, and whether existing Federal efforts in health information technology are optimized for these goals. To provide a solid scientific and economic basis for our recommendations, the Council assembled a Working Group of nongovernmental experts and also met with government officials, industry repre- sentatives, information technology experts, and healthcare professionals. PCAST has concluded that information technology can help catalyze a number of important benefits including improved access to patient data, which can help clinicians as they diagnose and treat patients and patients themselves as they strive to take more control over their health; streamlined monitoring of public health patterns and trends; an enhanced ability to conduct clinical trials of new diagnostic methods and treatments; and the creation of new high-technology markets and jobs. Health information technology can also help support a range of healthcare-related economic reforms needed to address our Nation’s long-term fiscal challenges. PCAST has also concluded that to achieve these objectives it is crucial that the Federal Government facilitate the nationwide adoption of a universal exchange language for healthcare information and a digital infrastructure for locating patient records while strictly ensuring patient privacy. More specifically, PCAST recommends that the Office of the National Coordinator for Health Information Technology and the Centers for Medicare and Medicaid Services develop guidelines to spur adoption of such a language and to facilitate a transition from traditional electronic health records to the use of healthcare data tagged with privacy and security specifications. PCAST hopes that its report will help lay a foundation for the decisions that you and others in the Federal Government must make. We are grateful for the opportunity to serve you and the country in this way and would be pleased to brief you or your staff if you have questions about our recommendations. Sincerely, John P. Holdren Eric Lander Co-Chair Co-Chair + v + Table of Contents About the President’s Council of Advisors on Science and Technology . i Co-Chairs . iii Members . iii Staff . iv Executive Summary . 1 PCAST Health Information Technology Working Group . 7 Co-Chairs . 7 Staff . 7 I. Introduction and Overview . 9 Introduction . 9 The Origins of This Study . 10 Analysis of the Problem . 10 The Present Federal Landscape . 12 Structure of This Report . 14 II. The Potential of Health IT . 15 Introduction . 15 Potential Benefits of Health IT: An Overview . 15 The Value of Patient-Specific Data to Patients . 18 The Value of Patient-Specific and Aggregated Data to Physicians. 19 The Value of Population Data for Research and Public Health . 21 Realizing the Potential of IT: A Data-Centric Approach . 22 Conclusion . 24 III. Health IT Today . 25 Introduction . 25 Historical Barriers to EHR Adoption . 25 Limitations of Present-Day EHRs . 26 Lessons from Early Adopters . 28 Health Information Exchanges . 31 New and Emerging Technologies . 32 The HITECH Act and Shifting Incentives. 34 Opportunities and Challenges for ONC and CMS . 34 Conclusion . 37 + vii + THE PATH FORWARD IV. Technology for an Integrated Health IT Ecosystem . 39 Introduction . 39 Earlier Models for Enabling Data Exchange . 39 Universal Exchange Using Metadata-Tagged Data Elements . 41 Data Element Access Services . 41 Advantages of the Tagged Data Element Approach . 43 V. Privacy and Security Considerations . 45 Introduction . 45 The Present Framework . 45 The Need for Strong, Persistent Privacy Protections . 46 Deleterious Effects on Medical Research and Care . 47 Data Security: How Good Is Good Enough? . 48 A Health IT Architecture for 21st-Century Privacy and Security. 49 Privacy Protection of Metadata-Tagged Data Elements. 51 VI. Economic and Regulatory Issues. 53 Introduction . 53 Standards and Incentives for Interoperability . 53 Creating a Data Exchange Infrastructure . 54 A Regulatory Structure for Data Access . 56 Competition to Supply Technology . 56 Innovation and Markets for Applications . 57 The Broader Economics of Healthcare . 58 Estimating Costs. 60 VII. Health Data and the Research Opportunity . 63 Introduction . 63 The Potential for Real-Time, Real-World, and Comprehensive Data . 64 Supporting Research Uses . 65 VIII. Guidance to Agencies . 69 Introduction . 69 A Feasible Roadmap to the Future . 69 Guidance on Necessary Design Choices . 71 Guidance on Meaningful Use Requirements . 73 IX. Recommendations . 77 + viii + TABLE OF CONTENTS Appendix A: Expert Input . 81 Appendix B: Acknowledgments . 85 Appendix C: Glossary . 87 Appendix D: Abbreviations . 91 + ix + Executive Summary Information technology (IT) has the potential to transform healthcare as it has transformed many parts of our economy and society in recent decades. Properly implemented, health IT can: • Integrate technology into the flow of clinical practice as an asset, while minimizing unproduc- tive data entry work. • Give clinicians real-time access to complete patient