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Strategy for Electronic Health Records

Country: 
USA
Partner Institute: 
The Commonwealth Fund, New York
Survey no: 
(4)2004
Author(s): 
Robin Osborn, The Commonwealth Fund
Health Policy Issues: 
New Technology, Pharmaceutical Policy, Role Private Sector, System Organisation/ Integration, Funding / Pooling, Quality Improvement, Remuneration / Payment, Responsiveness, HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes yes yes yes yes yes no

Abstract

In April 2004 President Bush announced his goal that most Americans have an Electronic Health Record (EHR) within the next ten years. A National Coordinator for Health Information Technology was appointed and in July 2004, the Health Secretary presented a plan for action to bring EHRs into physicians offices and hospitals by incentivizing EHR adoption and reducing risk.

Purpose of health policy or idea

U.S. Framework for Strategic Action on Electronic Health Records (EHRs)

On April 26, 2004 President Bush announced his goal that most Americans have an Electronic Health Record (EHR) within the next ten years.  The anticipated  benefits of EHRs that could share patient information securely among providers and ensure complete health information would be available at the time and place of care, would be: improved quality of care, reduced medical errors, reduced health care costs, improved administrative efficiencies, reduced paperwork, and increased access to affordable health care.  The President issued Executive Order 13335 and established the position of  National Coordinator for Health Information Technology, who was required to report within 90 days on a strategic plan to guide the national development and implementation of Health Information Technology (HIT) in both public and private sectors.

In May 2004, Secretary of Health and Human Services Tommy G. Thompson appointed David J. Brailer, MD, PhD to serve in this new position, and on July 21, 2004, presented  a report, "The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care -  Framework for Strategic Action."

The plan sets forth four major goals, each with a corresponding set of strategies and related actions to advance and focus efforts:

  • Goal 1: to bring EHRs  into physicians offices and practices, by developing incentives and shared investments in HIT, and reducing risk of EHR investment;
  • Goal 2: to build an interoperable health information infrastructure so that patient information is portable, the record follows the patient, and doctors have access to critical health care information at the time treatment decisions are being made; 
  • Goal 3: to personalize care by encouraging Personal Health Records, providing information on provider performance to encourage consumer choice, and promoting telehealth in rural and underserved areas;
  • Goal 4: to improve population health and expand public health surveillance systems ( for communicable diseases, unsafe imported foods, and terrorism) that allow for information exchange between providers, state and federal agencies, and by bringing research advances more quickly into practice.

 Key actions outlined to implement the strategy included:

  • Establishing a Health Information Technology Leadership Panel to evaluate the costs and benefits of  IT options, the urgency of investments, and recommend next steps for the public and private sector;
  • Working with the private sector to develop minimum certification standards for HIT products, such as decision support software, to reduce the financial risk of  product implementation failure;
  • Funding community/multi-stakeholder collaboratives to implement demonstration projects for health information exchange;
  • Assisting private sector organizations to develop the consortia that would plan and operate an interoperable national health information network consistent with public policy objectives;
  • Implementing e-health prescribing standards, in conjunction with requirements that Medicare Prescription Drug Plan Sponsors offer e-prescribing under the new Medicare Prescription Drug Benefit in 2006;
  • Providing consumer access to personal health information via the Internet for Medicare beneficiaries, beginning with a pilot project that will include claims information on dates of service and procedures, and then preventive health care reminders;
  • Bringing together government, academia and industry to agree on standards and a model that provides a secure infrastructure for the exchange of clinical research data; and
  • Having all Federal agencies agree to endorse and adopt 20 sets of standards, developed by the Consolidated Health Informatics initiative, to ensure the interoperability of health information across agencies and serve as a model for the private sector.

The President also included $100 million in his proposed FY 2005 budget for demonstration  projects by hospitals and health care providers to test the effectiveness of HIT technology and establish best practices for more widespread adoption in the health care industry.

The strategy is built on the premise that the adoption and effective use of HIT requires a joint effort between federal, state, and local government, and the private sector.  Stakeholders include: Federal, state and local governments, Medicare beneficiaries and all other consumers,  health care provider organizations, health care plans and insurers, purchasers, health care industry trade organizations, the IT industry, standards development organizations, consumer and patient advocacy groups, and academic and research organizations.

With this initiative, the U.S. Department of Health and Human Services (HHS) has taken on a leadership role in the development of a national health information infrastructure, building collaboration between the public and private sector, facilitating the adoption of standards for the interoperability of systems, privacy and confidentiality, encouraging capital investment, incentives, and market-based solutions.

(references #1, #2 and #3)

Main points

Main objectives

To support and encourage the adoption of Electronic Health Records for most Americans within the next 10 years; encourage adoption of EHRs in doctors' offices and hospitals; build an interoperable health information infrastructure; use health information technology to give consumers more access and involvement in health decisions;  improve public health monitoring  and surveillance, quality of care measurement, and bring research advances more quickly into practice.

Type of incentives

1)The President's proposed FY 2005 budget included $100 million for local and regional demonstration projects to help test the effectiveness of HIT

2) HHS will also explore a wide range of incentives, including: grants and contracts to regions, states, and communities for EHR adoption, incentives to the banking and loan industry to provide low rate loans for physician and provider adoption of EHRs, use of pay-for -performance demonstration projects, changes in the Medicare phyisician fee schedule for specific EHR uses, and use of contracting incentives in its role as a purchaser.

Groups affected

Congress and State legislatures, Medicare beneficiaries and all other consumers, Government agencies, including, the Centers for Medicare and Medicaid Services; Health care provider organizations; Third-party Payers; Purchasers; Health care industry trade organizations; Joint Commission for Accreditation of Health Care Organizations

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual neutral highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent neutral system-neutral

The public/private nature of the U.S. health care system has made it more challenging to adopt and implement a national IT program than it would be in a country with a national health care system and single payer.

The leadership role that the Federal government has assumed is a critical step forward and already has had demonstrable effects in coordinating key stakeholders, stimulating public-private partnerships, reducing risk through certification of IT products, gaining consensus on standards, and setting a timetable for universal implementation of an Electronic Health Record in the United States.

The single biggest policy issue, however, is how to compensate health care providers for investing in this technology. Like other medical technology used to diagnose, treat and monitor patients, EHRs have significant development, acquisition, and operating costs. Unlike equipment such as MRI machines, whose investment and operating costs are re-couped through the reimbursement system when they are used for patient care, the productive use of IT does not benefit from similar reimbursement. "Because of misaligned incentives, it is difficult to construct a business case for providers showing a return on investment measured in hard dollars. "  (PTang, Pennyhill Park Working Paper, 2004 , #14)

The government will need to demonstrate ongoing leadership to keep this initiative on track and will need to address and find workable solutions to high IT startup and operating costs for providers.  

Political and economic background

In 2002, only 13 percent of hospitals and 14%-28% of physicians' offices in the United States had Electronic Health Records (EHR) . The most frequently cited barriers were insufficient resources or negative returns on investment because of the high costs associated with EHR purchase, implementation, and operation. (#1)

On the cutting edge, however, were a few pioneer institutions or organizations, such as the Veterans Health Administration, the Regenstrief Institute (Indiana), Kaiser Permanente, Intermountain Health (Utah), Beth Israel Care Group Health System(Boston), Partners Health Care-Brigham and Women's (Boston), that had developed sophisticated systems which provided examples of most of the beneficial functions of EHRs.

Historically, there have been major barriers to the widespread implementation of EHRs in the U.S. health care system, largely attributable to: lack of uniform data standards; lack of incentives; insufficient funding and affordability of systems; lack of an effective business case for IT investment; piecemeal evolution of electronic health record systems that were not designed for data sharing, integration, and inter-operability; lack of  provider knowledge of what to buy; instability of the vendor community providing systems; concerns about physician resistance, productivity, and privacy.

At the same time, growing evidence was showing the benefits of EHRs, and high costs, medical errors, variable quality, administrative efficiencies, and lack of coordination in the health care system, were recognized by the Administration as being partly attributable to the inadequate use of HIT.

Prior to the President's announcement in April calling for all Americans to have Electronic Health Record (EHR) within the next ten years, and the Secretary's July 2004 report, providing the government's strategy for taking a leadership role in Health Information Technology (HIT),  both had strongly stated the importance of and need for more advanced information technology in health care.

In March 2003, Secretary Thompson said, "The medical revolution of our children's lifetime will be the application of information technology to healthcare. This is the year we can turn the corner."  (#10)

In President Bush's State of the Union Speech in January 2004, he said, "By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care."

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes yes yes yes yes yes no

Origins of health policy idea

The President and Department of Health and Human Services (HHS) recognized the importance of fostering IT development and implementation of EHRs and put forward a strategy that built on earlier recommendations, legislation, and public and private efforts:

  • In 1991 and 2000, the Institute of Medicine (IOM) Committee on Improving the Patient Record, called for a major public-private sector initiative to make computerized patient records the standard for all medical records related to patient care within a decade. (#8)
  • In 1998, the National Committee on Vital and Health Statistics (NCVHS), a Federal advisory committee of private sector experts produced a report that concluded that the national information infrastructure, which had been evolving with Federal support, conspicuously lacked a health dimension. In June 2000 it issued an Interim report with a vision for a National Health Information Infrastructure;"
  • In 2000, the Institute of Medicine (IOM) published its landmark report, "To Err is Human: Building a Safer Health Care System,"  that made headlines with its finding that as many as 98,000 Americans die each year from medical errors and pointed out the need for a computer-based patient record to provide doctors with access to a patient's record without delay at any time and in any place, measure and track outcomes of treatment, prevent errors and adverse events, provide clinical decision support grounded in evidence-based knowledge, etc  (#6)
  • In 2001, the National Committee on Vital and Health Statistics (NCVHS), produced at the request of the Secretary, a report, "Information for Health: A Strategy for Building the National health Information Infrastructure (NHII)," which underscored the urgent need for an effective, comprehensive health information infrastructure that links all health decisionmakers, including the public." It determined "that Federal leadership was the most important missing ingredient that could accelerate and coordinate progress on a NHII urged the Secretary of HHS to take a leadership role. (#12)
  • In 2001, the Institute of Medicine (IOM) published its sentinel report, "Crossing the Quality Chasm," which urgently called for a dramatic re-structuring and transformation of the health care system to innovate and improve care,  outlined the critical role of information technology in improving safety, effectiveness, patient-centered care, timeliness, efficiency, and equity.  It recommended that "Congress, the executive branch, leaders of health care organizations, public and private purchasers, and health informatics associations and vendors should make a renewed national commitment to building an information infrastructure to support health care delivery, consumer health quality measurement and improvement, public accountability, clinical and health service research, and clinical education. This commitment should lead to the elimination of most handwritten clinical data by the end of the decade."  (#7)
  • In 2002, the Markle Foundation organized a public-private collaboration, "Connecting for Health" which brought together over 100 stakeholders and achieved consensus on an initial set of health care data standards; (#1)
  • In March 2003, the Consolidated Health Informatics (CHI) initiative involving the Department of Health and Human Services, Veterans Administration, and Department of Defense, announced uniform standards for the electronic exchange of clinical health information to be adopted across Federal agencies;  (#1)
  • In March 2003, Secretary Thompson announced the endorsement of five major health data standards for the Veterans Administration, Department of Defense, and Indian Health Service, an important signal about the Federal government's assumption of a leadership role in advancing the adoption of IT in healthcare. In a significant step towards standardizing clinical terminology, the Secretary licensed SNOWMED  CT , which was developed by the College of American Pathologists, for all users in the United States.  (#10)
  • In May 2003, the Institute of Medicine prepared a Letter Report, at the request of the Department of Health and Human Services, outlining the key functionalities needed for an EHR in the inpatient, ambulatory care, nursing home, and community care setting; (#10)
  • "Connecting for Health," a $2.8 million Markle/Robert Wood Johnson Foundation Initiative, which includes 100 representatives of prominent providers, payers, government agencies, researchers, and the IT industry, released a preliminary road map for a common framework for a non-proprietary network of networks to link computer systems across the country, in July 2004, the week before the Secretary announced his plan.



Much of the legislative groundwork for the Administration's Framework for Strategic Action on Electronic Health Records (EHRs) was laid by President Bush, in December 2003, signing the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003, which included IT provisions.

It specifically:

1) required the Centers for Medicare and Medicaid to develop standards for electronic prescribing;

2) called for the establishment of a Commission on Systemic Interoperability;

3) authorized Medicare to contract with Quality Improvement Organizations (QIOs) to lead new Medicare Demonstration Projects that use Information Technology to improve chronic disease management services for Medicare patients;

4) and, authorized the HHS Secretary to make grants to physicians to help defray the costs of purchasing, leasing, installing, and upgrading computer software/hardware, including for electronic prescribing.

Innovation or pilot project

Within institution - The Veterans Health Administration?s primary health information system and Electronic Health record, VistA has been made available in the public domain as a means of fostering widespread development of high performance EHR systems.(#1)

Stakeholder positions

The idea was brought forward by the President of the United States and the Secretary for Health and Human Services.

The stakeholders, many of whom had been addressing the issue of several decades, included:

1)  Congress and State legislatures

2)  Medicare beneficiaries and all other consumers

3) Government agencies, including, the Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control (CDC), Food and Drug Administration (FDA), Veterans Health Administration (VHA), National Library of Medicine (NLM), Department of Defense (DoD)

4) Health care provider organizations

5) Third-party Payers

6) Purchasers

7) Health care industry trade organizations

8) Joint Commission for Accreditation of Health Care Organizations (JCAHO)

9) IT industry

10) Standards development organizations

11) Consumer and patient advocacy groups

12) Academic and research organizations.  

For further description of stakeholder responses, see Section 5.4

Influences in policy making and legislation

The President issued Executive Order 13335 and established the position of  National Coordinator for Health Information Technology, who was required to report within 90 days on a strategic plan to guide the national development and implementation of Health Information Technology (HIT) in both public an dprivate sectors.

In May 2004, Secretary of Health and Human Services Tommy G. Thompson appointed David J. Brailer, MD, PhD to serve in this new position, and on July 21, 2004, presented a report, "The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care -  Framework for Strategic Action."

Adoption and implementation

All of the stakeholders listed in Section 5.2 are involved.

The response to the President's announcement was generally very positive.

Republicans and Democrats in Congress vowed to support or propose legislation to advance the issue. Senate Majority Leader Bill Frist (Republican-Tennessee) and Senator Hillary Rodham Clinton (Democrat-NY) joined together in an op-ed in the Washington Post (August 25, 2004) in support of the IT agenda. With bipartisan support, several bills were introduced in Congress to encourage IT in support of improved quality of care and patient safety.

Concerns raised about the Adminstration's policy focused on:

1) who would pay for development and acquisition of EHRs,

2) privacy issues, and

3) anti-fraud issues.

Medical and health care groups, such as the American Medical Association and American College of Physicians, were enthusiastic, but expressed concern that there was no established funding stream to pay for the widespread development and dissemination of electronic health records.

Key national organizations, such as the American Medical Association, the American Academy of Family Physicians, the American College of Physicians, the eHealth Initiative, and National Council on Quality Assurance, were very supportive, however, of the Doctors Office Quality-Information Technology Project (DOQ-IT), which under the MMA will provide support to doctors in small to medium-sized offices to implement Electronic Health Records.

A new coordinating organization for payers and large employers, the National Alliance for Health Care Technology Information Advancement, which represents nearly 200 million people covered by health insurance, was established in July to determine what they would pay for to encourage IT adoption. The group, which includes the National Business Group on Health, Blue Cross and Blue Shield Plans and America's Health Insurance Plans, and the American College of Physicians, noted that it  "wants to ensure that government and providers pay their share. If we're going to foot 60 percent of the bill, we expect Medicare to foot the other 40 percent,"  (J. Morrissey, "Show Them Money: Health Care Providers Say it Will Take More Than Vision to Turn the Government's Health IT Plans into reality," Modern Health Care, July 26, 2004.)

The American Academy of Family Physicians noted that the payers are the most likely beneficiaries of the $100 billion in annual savings that could be reaped if EHRs were universally adopted, and recommended that there be strong financial incentives from payers to physicians, (J. Morissey, "Show Them Money: Health Care Providers Say it Will Take More Than Vision to Turn the Government's Health IT Plans into reality," Modern Health Care, July 26, 2004.)

Concerns about confidentiality and security and medical malpractice have been and will continue to be raised by patients, consumer advocacy groups, providers, insurers, Congress and State legislatures, until comprehensive privacy legislation covering all parties with access to patient data is enacted.

Providers also raised concerns about vulnerability for prosecution under anti-kickback or anti-fraud statutes, under current fraud and abuse laws, if they accept certain kinds of HIT from health systems, according to the Government Accountability Office. 

Monitoring and evaluation

The Secretary's "The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care -  Framework for Strategic Action." calls for the National Coordinator to work with Federal agencies to develop metrics to assess the effectiveness of progress towards strategic goals over time and across programs.

Expected outcome

The Administration's July 2004 report, "The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care -  Framework for Strategic Action," represents a major step forward in setting out a Federal leadership role in HIT and adoption of electronic medical records and in making this a priority for improving quality and safety in the U.S. health care system. 

The role of the Administration in spearheading, accelerating, and coordinating this effort is essential. The leverage that it can bring through Medicare and Medicaid, which cover 25 percent of the US population, as the nations' largest employer purchaser  of health care benefits for over 8 million people, and its ability to impose a mandate on government agencies─ the Veteran Health Administration, the Department of Defense, and the Indian Health Services, which operate the largest health care delivery ─ cannot be matched.

The program sets targets, outlines a market-oriented approach that builds on public-private sector collaboration, sets out a strategy to address barriers and support widescale IT adoption, and calls for developing the necessary incentives to move the plan forward.

The Administration policy has clearly had some impact already in moving the industry forward:

  • A new coordinating organization for payers and large employers, the National Alliance for Health Care Technology Information Advancement, which represents nearly 200 million people covered by health insurance, was established in July 2004 in anticipation of the release of the Secretary's strategy, to determine what they would pay for to encourage IT adoption.  
  • The Certification Commission for Health Care Information Technology, a 13-member private sector certification commission was established to determine the minimum set of features and functions to be included in the ambulatory electronic record and set requirements for ensuring interoperability. The Commission represents healthcare providers, IT vendors, payers and purchasers, and IT standards organizations.
  • Planning for the National Health Information Network got underway in November 2004 with the release of a government Request for Information on how to achieve widespread interoperability of health information.
  • Under the Doctors Office Quality-Information Technology Project (DOQ-IT), which was authorized under the MMA, Quality Improvement Organizations in California, Utah, Arkansas, and Massachusetts, are developing a model for providing free consulting to assist doctors in small to medium-sized offices to implement Electronic Health Records.
  • In October 2004, the Agency for Healthcare research and Quality(AHRQ) announced $139 million in grants to help small and rural hospitals implement health information technology; develop Statewide and regional networks to facilitate sharing of patients' health information between health care providers and ensure security and privacy; and, establish a National Health Information Technology Resource Center.  (see reference #15)



In terms of expected impact, there is a growing body of evidence that CPOE and clinician decision support can reduce medication errors ─ e.g. a study at LDS Hospital in Salt Lake City demonstrated a 75 percent reduction in adverse medical events and one at Regenstrief Institute in Indianapolis demonstrated that computerized reminders increased orders for appropriate interventions by 22 to 46 percent. Studies have also shown that EHRs can reduce laboratory and radiology test ordering by 9 percent to 14 percent, hospital admissions by 2 percent, and excess medication prescribing by 11 percent. (#1, page 3)

It is too early to know whether the President's policy will achieve its full objective of everyone in America having an electronic health record within ten years and the related impacts. "Secretary Thompson estimated that adoption of EHR systems nationally could save  10 percent of the nation's current annual $1.7 trillion health care bill. He also said that EHRs would improve privacy, better protect medical records and decrease medical errors while reducing administrative costs." Estimated costs for implementing EHRs nationwide are $10 billion. ("HHS Pushes Electronic Health Records," COMPUTERWORLD, August 2, 2004)

A leading U.S. expert, Dr Brent James of Intermountain HealthCare in Salt lake City, said, "the savings from streamlining the health care system with electronic health records could eventually amount to $400 billion per year ,"("HHS Pushes Electronic Health Records," COMPUTERWORLD, August 2, 2004)

Another leading expert, Charles Safran, M.D., president of the American Medical Informatics Association, "called President Bush's goals both realistsic  and attainable," and said, "The national health information infrastructure will profoundly improve the health.  Seamless and interoperable transmission of health data will increase efficiency, improve quality of care, reduce medical errors, and reduce administrative costs."  (AM News, May 17, 2004)

Impact of this policy

Quality of Health Care Services marginal fundamental fundamental
Level of Equity system less equitable two system more equitable
Cost Efficiency very low very high very high

The Federal government's assumption of a leadership role in accelerating the adoption of IT in the health care industry is a critical step forward. 

The ultimate impact of this policy will, however, depend, on the extent to which effective public-private partnerships are established, the work on standards and inter-operability progresses as planned, privacy and anti-trust concerns are resolved, and, most importantly, effective financial incentives to assist with capital acquisition costs and ongoing operating costs are made available.

References

Sources of Information

1. Secretary of Health and Human Services, Tommy G. Thompson, and David J. Brailer, M.D., "The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care- Framework for Strategic Action." Progress Report published by U.S. Department of Health and Human Services, July 21, 2004

2. "Thompson Launches a Decade of Health Information Technology", U.S. Department of Health and Human services, http://www.hhs.gov/news/press/2004pres/2004072a.html

3. "A New Generation of American Innovation," The White House.  April 2004.

4. eHEALTH INITIATIVE, "How Health Care Technology Can Improve Health Care Quality," Alliance for Health Reform/Commonwealth Fund Roundtable, November 14, 2003.

5. GAO Highlights, "Information Technology: Benefits Realized for Selected Health Care Functions,"  www.GAOgov/cgi-bin/getrpt?GAO-04-224

6. Kohn, LT, Corrigan, JM, Donaldson MS (eds) "To Err is Human: Building a Safer Health Care System," Institute of Medicine, National Academy of Sciences. National Academy Press,  Washington, DC 2000.

 7. "Crossing the Quality Chasm: A New Health System for the 21st Century," Institute of Medicine, National Academy of Sciences. National Academy Press,  Washington, DC 2001.

8. Dick, RS, Steen, EB, Detmer, DE (eds)"The Computer-Based Patient Record: An Essential Technology for Health Care,"  Institute of Medicine, National Academy of Sciences. National Academy Press,  Washington, DC 2000.

9. FAQ for the National Health Information Infrastructure, http://aspe.hhs.gov/sp/nhii/FAQ.html

10. Tang, PC "Key Capabilities of an Electronic Health Record, Letter Report" Committee on Data Standards for Patient Safety, Institute of Medicine, National Academy of Sciences. National Academy Press,  Washington, DC 2003

11. Bates, DW, and Gawande, A.A., "Improving Safety with Information Technology," The New England Journal of Medicine, 2003; 348:2526-2534.

12. "Information for Health: A Strategy for Building the National health Information Infrastructure, Report and recommendations from the National Committee on Vital and Health Statistics (NCVHS), November 15, 2001.

13. JM Marchibroda, JM Teich, "Electronic Prescribing: Toward Maximum Value and Rapid Adoption," eHealth Initiative, April 14, 2004.

14. Tang, PC "Electronic Health record System Support of Patient Safety and Quality: A Matter of Policy,"  Working paper, not published, for the Commonwealth-Fund Nuffield Trust Pennyhill Park Meeting, July 2004.

15. "HHS Awards $139 Million To Drive Adoption of Health Information Technology, " HHS Press Release, October 13, 2004, www.ahrq.gov/news/press/pr/hhshitpr.htm

Author/s and/or contributors to this survey

Robin Osborn, The Commonwealth Fund

Suggested citation for this online article

Robin Osborn, The Commonwealth Fund. "Strategy for Electronic Health Records". Health Policy Monitor, October 2004. Available at http://www.hpm.org/survey/us/c4/2