typically occurs in larger and “more wired” facilities—referred to as the “adoption gap” between large and small organizations (Brailer and Terasawa, 2003). Many hospitals have made progress in adopting certain EHR components, such as automated laboratory results. Use of EHRs is higher in ambulatory settings—approximately 5 to 10 percent of physician offices—but there is much variation in their content and functionality (IOM, 2004). The federal strategic framework identifies the total cost of EHRs (purchase price + implementation costs + maintenance costs + impact on operations) as the primary impediment to their more widespread adoption (Thompson and Brailer, 2004).

The federal government’s NHII strategic framework calls for the adoption of interoperable EHRs within 10 years (Thompson and Brailer, 2004). Several activities are under way to help achieve this goal. The IOM has provided a framework that should prove useful to accreditation organizations in establishing standards for EHR systems, as well as to providers in selecting vendors to design such systems (IOM, 2004). Standards for EHRs are under development by Health Level 7, the leading private-sector standards-setting organization (Thompson and Brailer, 2004). Three leading associations in health care information management and technology—the American Health Information Management Association, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology—have jointly launched the Certification Commission for Healthcare Information Technology to create a mechanism for the certification of health care information technology products, in particular EHRs (CCHIT, 2004).

The Veterans Health Administration has used an EHR system (VistA) for over two decades for its physicians, clinics, and hospitals. VistA is in the public domain, and in September 2005 Medicare released an evaluation version of the system (Vista-Office) for use by private physicians’ offices in computerizing their medical practices. This evaluation version will be assessed to determine the extent to which physician offices can implement the software effectively. The evaluation phase will also allow software vendors to improve upon the system and develop a version that meets any standards for EHRs (CMS, 2005). Medicare will provide doctors with lists of companies that have been trained to install and maintain the system. Because so many doctors participate in Medicare, the distribution of Vista-Office is viewed as a significant development in the advancement of EHRs (Kolata, 2005).

Data Standards

In addition to cost factors, efforts of both the public and private sectors to invest in IT are hampered by the lack of nationwide standards for the

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