Many factors have contributed to the information/ communications technology deficit: (1) the atomistic structure of the industry (the prevalence of relatively undercapitalized small businesses/provider groups); (2) payment/reimbursement regimes and the lack of transparency in the market for health care services, both of which have discouraged private-sector investment in information/communications systems; (3) historical weaknesses in the managerial culture for health care; (4) cultural and organizational barriers related to the hierarchical nature and rigid division of labor in health professions; and (5) the relative technical/functional immaturity (until very recently) of available commercial clinical information/communications systems.


The idea of transforming paper medical records into electronic medical records (EMRs) was first considered in the mid-1960s, when early prototype systems were developed. A number of large integrated health care provider organizations were early adopters of EMR systems, including Massachusetts General Hospital (COSTAR) in the 1960s, Indiana University Medical School (Regenstrief Medical Record System) in the early 1970s, and others (Kass-Bartelmes et al., 2002; Lindberg, 1979). However, there was little diffusion of these systems in the next two decades. In 1991 and 1997, IOM issued reports documenting the magnitude and implications of the large information-technology gap in U.S. health care and called for the adoption of EMRs as a first, critical step in moving health care delivery toward information/communications-technology-supported improvements in quality performance achieved in other industries (IOM, 1991, 1997).

Building on these studies, a series of reports by IOM, the National Committee on Vital and Health Statistics (NCVHS), and other organizations in the past five years have documented the profound negative impact of the information/ communications technology deficit on patient safety, the number of medical errors, and the quality and cost of care; every one of these reports calls for the development of a comprehensive health care information infrastructure (e.g., NHII) to help close the gap (IOM, 2000, 2001, 2003, 2004; NCHVS, 2001; NRC, 2000).

In Information for Health: A Strategy for Building the National Health Information Infrastructure, NCVHS described the NHII as both infrastructure and a defined set of components linked explicitly to health care delivery processes (NCVHS, 2001). IOM (2004) summarized the NCVHS definition as follows:

The NHII is defined as “a set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health”… It encompasses an information network based on Internet protocols, common standards, timely knowledge transfer, and transparent government processes with the capability for information flows across three dimensions: (1) personal health, to support individuals in their own wellness and health care decision making; (2) health care providers, to ensure access to complete and accurate patient data around the clock and to clinical decision support systems; and (3) public health, to address and track public health concerns and health education campaigns.

This stream of reports from IOM, NCVHS, and others catalyzed a number of actions in the private and public sectors intended to lay the groundwork for and build momentum toward realization of the NHII (IOM, 2004; PITAC, 2004; Thompson and Brailer, 2004; Yasnoff et al., 2004). Inspired by the 1999 IOM report, To Err Is Human, the Leapfrog Group for Patient Safety, a coalition of large companies established expressly for the purpose of using their market power as major purchasers of health care to encourage care providers to improve the safety, quality, and efficiency of health care. The Leapfrog Group called on all health care provider organizations serving Leapfrog members’ employees to use information/communications systems (EMRs and computerized physician order entry [CPOE] systems in particular) (see paper by Milstein in this volume).

In April 2004, progress toward an NHII was given new impetus when President Bush called for national implementation of EMRs and announced the creation of the Office of the National Coordinator for Health Information Technology (ONCHIT) in the U.S. Department of Health and Human Services (DHHS); Dr. David Brailer was appointed the first national coordinator. In July, DHHS released a report outlining a 10-year plan to build an NHII, including the creation of electronic health records (EHRs), for all Americans (Thompson and Brailer, 2004). In November 2004, ONCHIT issued a Request for Information (RFI) for a National Health Information Network (NHIN), soliciting proposals for ways to advance interoperability and standards. As of early 2005, ONCHIT had received more than 500 responses from a wide variety of organizations and collaboratives.

One of the respondents to the RFI, the Interoperability Consortium, an alliance of eight information-technology systems vendors (Accenture, Cisco, CSC, Hewlett-Packard, IBM, Intel, Microsoft, and Oracle), describes the current challenges to interoperability:

Dozens of communities and innovative networks across America have begun implementing information exchange solutions—yet they are following no common pathway, no uniform standards, and have established no basis for eventual information exchange among them or with the important national information networks already in existence. A common framework is needed to guide and maximize the value of the enthusiastic efforts already in the field.

In its preliminary blueprint for NHIN, the Interoperability Consortium (2005) stresses that the NHIN must be part of an

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