Aw

Issue Brief

CHCF

 

JUNE 2022

by Walter Sujansky, MD, PhD

An Assessment of the California Health
Information Technology Landscape in 2022:

Summary of Key Findings

ver the past 12 years, California has collab-
C) orated with the federal government to help

support the state's Medicaid providers in
adopting and using electronic health record systems
(EHRs). Under the terms of this arrangement, the
state was required to periodically prepare and deliver
a State Medicaid Health Information Technology (IT)
Plan. An important component of this plan is a Health
IT Landscape Assessment, which describes the current
health IT environment in California. The assessment
is intended to report the current state of health IT
adoption and use among a wide variety of stakehold-
ers, past trends in the adoption and use of health IT
during the period of federal support, and remaining
challenges in achieving full adoption and optimal use
of health IT in the future. The latest version of the
California Health IT Landscape Assessment was com-
pleted in early 2022 by researchers from the Clinical
Informatics Improvement and Research group at the
University of California San Francisco, along with staff
at the California Department of Health Care Services
(DHCS).' This brief summarizes a number of key find-
ings from the assessment.

To prepare the assessment, the researchers collected
data from primary and secondary resources including
nationwide surveys of hospitals, office-based physi-
cians, family practitioners, skilled nursing facilities,
substance use disorder treatment facilities, and health
information exchange organizations (HIOs). These sur-
veys were conducted over the past 8 to 10 years. The
researchers also analyzed data from DHCS regarding
participation in the state's Electronic Health Record
Incentive program (recently renamed the Promoting

Interoperability Program), as well as results from a
state-funded initiative to increase hospital and phy-
sician participation in California HlOs. Although the
survey data and DHCS data generally provide mean-
ingful sample sizes, many of the data points extend
only through 2018 or 2019 and, therefore, provide
a slightly lagged snapshot of the current landscape.
Finally, in 2021 and 2022, the researchers interviewed
over two dozen health IT leaders and stakeholders in
California to collect expert, albeit anecdotal, infor-
mation about key aspects of the current health IT
landscape.

The Medi-Cal EHR Incentive Program drew to a close
at the end of 2021. However, the state has ambitious
plans to leverage the increased adoption and use of
health IT that the program spurred to improve the
effectiveness and efficiency of Medi-Cal. Specifically,
the CalAIM (California Advancing and Innovating
Medi-Cal) program intends to modernize the delivery
of health care and other social benefits by integrat-
ing the provision and management of numerous
state-run programs." This initiative relies on the
streamlined electronic sharing of enrollees' medi-
cal, behavioral, and social service data, a task heavily
dependent on effective and widespread health IT. To
facilitate such sharing, the state has also launched the
California Health and Human Services Data Exchange
Framework.? This initiative will establish a single data
sharing agreement and common set of policies and
procedures to govern and require the exchange of
health information among health care entities and
government agencies in California. The current health
IT landscape, as objectively characterized in the recent
landscape assessment, helps to inform the planning
and execution of these important modernization
projects.

Assessment Key Findings

The remainder of this brief highlights and summa-
rizes several key findings of the California Health IT
Landscape Assessment and their potential implica-
tions for programs such as CalAIM. Many details and
additional important findings are omitted from this
brief, however, so interested readers are encouraged
to review the full assessment.

HITECH Act funding and the
"meaningful use" programs
significantly helped medical providers
to adopt EHRs and gain the capabilities
to exchange patient data electronically.

The HITECH (Health Information Technology for
Economic and Clinical Health) Act of 2009 was legisla-
tion created to stimulate the adoption of EHRs across
the US. It included a "meaningful use" program,
which offered incentives for Medicare and Medicaid
providers (inpatient and outpatient) who could dem-
onstrate that they had an EHR and could meet certain
use requirements. Available data starkly demonstrate
that the levels of EHR adoption among hospitals and
outpatient physicians in California steadily and sub-
stantially increased due to the Medicare and Medicaid
meaningful use programs, which provided incentives
for, funded, and technically supported eligible health
care provider organizations to procure and use clinical
information technology.

EHR Adoption by Hospitals

According to longitudinal surveys conducted by the
American Hospital Association (AHA), the proportion
of California hospitals that had adopted at least a basic
EHR* climbed to 96% by 2018 (see Figure 1). Today, it
is likely that virtually all California hospitals use some
type of EHR, double the rate of EHR adoption in 2012
(the modest decline in EHR adoption in 2019 was
probably a technical artifact owing to changes that
year to the wording of survey questions regarding EHR
adoption). Figure 1 shows that the subset of California
hospitals that had adopted a comprehensive EHR also
rose steadily during the 2010s, with nearly two-thirds
of California hospitals using such an EHR by 2019.

Although the AHA survey data indicated somewhat
different EHR adoption rates between small and large
hospitals and between urban and rural hospitals,
these variations were minor relative to the degree that
all types of hospitals increased their use of EHRs (for
example, small hospitals achieved a 90% adoption
rate by 2018, whereas large and medium-sized hospi-
tals achieved a 100% adoption rate).

Figure 1. California Hospitals Adopting an EHR, 2012-19

 

96.6%

 

2012 «2013-2014. 2015S 2016) = 2017's 2018 = 2019

MM Basic EHR [ll Comprehensive EHR

Source: Julia Adler-Milstein et al., California Health IT Landscape Assessment:
Final Report - February 2022, California Dept. of Health Care Services.

 

California Health Care Foundation

www.chcf.org 2
Consolidation in the Hospital EHR Market
During this time period, two vendors came to increas-
ingly dominate the hospital EHR market in California:
Cerner and Epic. The AHA survey indicated that
the combined market share of these two vendors
increased from 34% to 61% between 2012 and 2019
(see Figure 2), with the share gained by Epic and
Cerner ceded primarily by Meditech, McKesson, and
Siemens (although the latter was acquired by Cerner
in 2015).

Figure 2. EHR Vendor Market Share Among California
Hospitals, 2012 vs. 2019

 

© Others
@ cps

Bi Allscripts
i Siemens
™ McKesson
Hi Meditech
© Epic

M@ Cerner

 

2012 2019

Source: Julia Adler-Milstein et al., California Health IT Landscape Assessment:
Final Report - February 2022, California Dept. of Health Care Services.

Within segments of the California EHR market, Cerner
dominated among small hospitals in 2019, and Epic,
to a lesser degree, led among large hospitals. In urban
areas, Epic and Cerner were used by roughly the same
proportions of hospitals, although in rural settings,
Cerner was favored by a factor of almost six to one.

EHR Adoption by Outpatient Physicians
Based on surveys of office-based physicians in
California, 79% of respondents adopted some type of
EHR system by 2017 (the most recently available data),
with 73% having adopted a system certified to include
the comprehensive features required by the federal
meaningful use program.® However, primary care phy-
sicians (PCPs) appeared to have adopted EHRs at a
somewhat higher rate than their specialist colleagues,
with 84% of PCPs reporting use of a certified EHR by
2015 versus 71% of specialists. Interestingly, the survey
data indicated that PCPs' adoption of EHRs, both cer-
tified and uncertified, did not increase between 2013
and 2017, a time during which hospitals' adoption of
EHRs in California roughly doubled (see Figure 1).

More recent survey data, however, suggest that the
adoption of EHRs among primary care physicians con-
tinued to rise. In 2019-20, 97% of family medicine
physicians surveyed at the time they took their board
exams reported that they used an EHR in practice. The
very high adoption rate within this cohort, which likely
skewed toward younger physicians, suggests that EHR
use in outpatient care may continue to increase with a
new generation of "digital native" doctors.

 

An Assessment of the California Health Information Technology Landscape in 2022: Summary of Key Findings 3
Data Exchange by Hospitals

The AHA longitudinal survey of hospitals also solic-
ited information about respondents' electronic data
exchange - that is, whether or not the hospitals in
California engage in the four primary domains of elec-
tronic data exchange: finding, sending, receiving,
and integrating patient data with outside systems.
The results of this survey (see Figure 3) indicate that
engagement in all four domains increased steadily
between 2014 and 2020, with 89% of hospitals send-
ing patient data electronically by 2020, and 74% of
hospitals integrating data sent by others into their own
systems (the latter rate having increased substantially
from just 27% in 2014).

Figure 3. California Hospitals Engaging in Each Domain of
Health Information Exchange, 2014-20

 

- Find os=Send == Receive == Integrate
100%
70% 89.0%
9, 81.5%
nor 77.1%
74.3%
70%
65.9%
60%
50%
40%
38.0%
34.1%
30%
27.3%

20%

10%

2014 2015 2016 2017 2018 2019 2020

Source: Julia Adler-Milstein et al., California Health IT Landscape Assessrnent:
Final Report - February 2022, California Dept. of Health Care Services.

Most dramatically, the proportion of California hos-
pitals engaging in all four domains of interoperability
increased eightfold, from 7% to 59%, over the same
period, enabling the state to close a substantial gap
with the rest of the nation (see Figure 4). The mean-
ingful use program's financial incentives for Medicare
and Medicaid providers to demonstrate engagement
in interoperability, along with EHR-certification criteria
that required health IT vendors to support interoper-
ability, clearly galvanized California hospitals to begin
engaging in all facets of data exchange.

Figure 4. California Hospitals Engaging in All Four
Domains of Health Information Exchange,
2014-20

 

-= California = United States

100%
90%
80%

70%
62.4%
60% 58.6%

50%

40%

30%
27.7%

20%

10%
7.2%

2014 2015 2016 2017 2018 2019 2020

Source: Julia Adler-Milstein et al., California Health IT Landscape Assessment:
Final Report - February 2022, California Dept. of Health Care Services.

 

California Health Care Foundation

www.chcf.org 4
Data Exchange by Outpatient Physicians

The health IT (HIT) landscape assessment does not
indicate the degree of engagement in health informa-
tion exchange (HIE) by California outpatient providers,
owing to a paucity of available data on this topic. The
available data showed only that 80% of outpatient
physicians participating in the California Medicaid
meaningful use program opted out of reporting the
frequency with which they exchanged health informa-
tion, an option available to physicians who did not
participate in a sufficient number of care transitions
involving Medicaid patients.

Although most hospitals and other
eligible entities can send patient data
electronically, the degree of data
sharing and the value of data received
can be improved.

The technical capabilities of EHRs to find, send,
retrieve, and integrate data and the meaningful use
incentives for provider organizations to engage in
these activities have not necessarily resulted in the rou-
tine electronic sharing of patient data. For example,
the 190 hospitals reporting to the California Medicaid
meaningful use program in 2018 indicated that they
sent an electronic summary-of-care record for only
33% of the patients they discharged (on average). This
modest rate prevailed although 89% of California hos-
pitals responding to the AHA survey the same year
indicated that they engaged in sending electronic
health data at least some of the time. Further, the
33% rate of sending electronic summary-of-care docu-
ments remained unchanged over the 2015-18 period.
It's possible, therefore, that the meaningful use incen-
tives prompt only minimal rather than universal patient
data sharing. As one interview subject stated:

"I don't think HITECH did a very good job of
actually putting [data sharing requirements]
in place and making it a requirement
that you not only have a system, but you
exchange [data]."

As another example, hospitals reporting to the
California Medicaid meaningful use program in 2018
indicated that they made clinical data available elec-
tronically for 90% of their patients. However, these
hospitals also reported that only 10% of their patients
actually accessed these data.

Finally, health IT stakeholders interviewed for the
landscape assessment anecdotally related that, even
when data are shared electronically, they are often too
voluminous or not sufficiently structured to meet the
practical needs of recipients:

"We heard over and over again that while
there was data exchange happening as a
result of HITECH, it was not meaningful data
exchange. It was a lot of big data dumps,
not sortable, not ingestible, and not usable,
and with no obligation to actually exchange
data, just meet the letter of the law."

 

An Assessment of the California Health Information Technology Landscape in 2022: Summary of Key Findings 5
Participation by health care providers
in regional and local HIE organizations
has grown substantially, but many HIOs
face financial sustainability issues and
other barriers.

Among the ways that health care providers in California
exchange clinical data are through regional and local
HIE organizations (HIOs), so it is important to under-
stand how these entities are faring. California currently
has 12 such HIOs serving various parts of the state.
Hospital participation in these organizations increased
substantially between 2012 and 2019, per data from
the AHA longitudinal hospital survey (see Figure 5). By
2019, 78% of California hospitals reported participating
in an HIO, increasing from 25% in 2012 and surpassing
the national average of 67%. Large and medium-sized
hospitals in California participated in HIOs at a some-
what higher rate (both approximately 80%) than small
hospitals (68%). However, urban and rural hospitals
participated in HlOs at equal rates by 2019 (both about
78%) after urban hospitals gradually closed a 27 per-
centage point deficit that existed in 2012.

Figure 5. California Hospitals Participating in a Health
Information Exchange Organization, 2012-19

 

= California) = United States

100%
90%

80% 77.2%

70%
66.9%
60%

50%

40%

30%
25.1%
24.5%

20%

10%

2014 2015 2016 2017 2018 2019 2020

Source: Julia Adler-Milstein et al., California Health IT Landscape Assessment:
Final Report - February 2022, California Dept. of Health Care Services.

The Cal-HOP Program

Today, the proportion of California hospitals that
participate in HIQOs is likely even higher than in 2019
owing to the efforts of the recent Cal-HOP (California
HIE Onboarding Program) initiative. Cal-HOP was a
federally funded, state-managed program to sub-
sidize the costs for health care organizations to join
HIOs, including the costs for legal contracting, techni-
cal data integration, and EHR vendor services. Using
Cal-HOP funds, 63 hospitals joined a California HIO
between 2019 and 2021 or expanded their existing
data sharing relationships with an HIO. Cal-HOP fund-
ing also assisted 330 outpatient practices to create
or extend data sharing arrangements with HIOs, help
that was particularly useful for providers working with
underserved populations. As one HIO interviewee
stated:

"[Cal-HOP] allowed us to onboard small
provider practices in our region that
participate in Medi-Cal."

Although the Cal-HOP program provided substantial
benefits, it was not without its challenges and limita-
tions. As reported by participating stakeholders, the
delayed availability of the funding at the outset com-
bined with a federally imposed deadline to end the
program in 2021 resulted in a shortened implementa-
tion timeline for HlIOs and provider organizations. The
end result was an inability to onboard as many new
hospitals and ambulatory practices as could have oth-
erwise participated.

 

California Health Care Foundation

www.chcf.org 6
Barriers to HIOs' Further Growth

and Development

Despite greater numbers of hospitals and other pro-
vider organizations participating in California HlOs,
a survey of these HIOs in 2019 uncovered persistent
barriers to achieving long-term growth and sustain-
ability (see Figure 6). Foremost among these barriers
(cited by 75% of respondents) was competition from
health IT vendors offering HIE solutions already inte-
grated with providers' EHRs, such as Carequality or
Epic Care Everywhere. HIO survey respondents also
mentioned the challenges of developing sustainable
business models (42%) and integrating their sepa-
rately hosted services into provider workflows (33%).
Interestingly, none of the California HlOs cited con-
cerns about privacy and confidentiality as a barrier to
ongoing development, although such concerns were
a challenge mentioned by 15% of the HIOs respond-
ing to the same survey nationwide.

Figure 6. Self-Reported Barriers to Further Growth and
Development Among California HIOs, 2019

 

Competition from Health IT Vendors Offering HIE Solutions
Thy
63%

Developing a Sustainable Business Model
LL
Rye

Integration of HIE into Provider Workflow
CRY)

wy)

Limitations of Current Interface Standards
33%
19%

Concerns About Privacy and Confidentiality
<1%
| _ B® California
fe)
15% MH United States

Source: Julia Adler-Milstein et al., California Health IT Landscape Assessment:
Final Report - February 2022, California Dept. of Health Care Services.

Finally, during interviews in early 2022, the leaders of
several California HlIOs mentioned the need for further
financial and policy support from the state government
(beyond the recently concluded Cal-HOP program) to
achieve greater provider participation and long-term
sustainability. The following quotes from two of these
leaders are emblematic of these sentiments:

"My hope for [the] future is that we have
a combination of data sharing mandates
through AB 133. | very much hope we have
a set of data sharing incentives - that
doesn't exist yet in policy - but I'm hoping
we can get there. And then a variety of
other policy nudges that get the providers
to the table so the HIEs aren't bearing the
brunt of all of that work."

"Whatever comes out, in terms of federal
or state initiatives around HIE, has to
involve both provider incentives and
also earmarking funding to support the
HIEs - the basic, general operation of
the HIE. Implementation and onboarding
resources like Cal-HOP [are] great and they
definitely help, no question, but | think we
can't overlook the need of the operational
expenses .. . to keep it all going."

 

An Assessment of the California Health Information Technology Landscape in 2022: Summary of Key Findings 7
The electronic exchange of public
health data has improved, but provider
organizations cite remaining barriers
to effective electronic reporting

and exchange that will need to be
addressed by public health agencies.

Health IT stakeholders interviewed in early 2022 anec-
dotally stated that the meaningful use requirements
of HITECH had accelerated the electronic reporting
of public health data on the part of providers and
provider organizations to a current level of "probably
90%." However, based on data from the AHA surveys
in 2017-19, California hospitals also experienced a
number of barriers and challenges to exchanging data
with public health agencies.

Foremost, about 45% of the responding hospitals
indicated that public health agencies lacked the
capacity to electronically receive immunization data,
lab results, surveillance data, case reports, and other
information typically collected for public health pur-
poses. In 2019, rural hospitals reported this challenge
somewhat more than urban hospitals (52% vs. 44%),
suggesting that public health agencies in rural areas
may have fewer resources to support electronic data
reporting. Further, roughly one-third of California hos-
pitals reported that interface-related issues (e.g., costs
and complexity) made it difficult to send information
electronically to public health agencies (presumably,
even when public health agencies had the capac-
ity to receive it). Again, rural hospitals reported this
challenge in 2019 more than urban (42% vs. 29%),
suggesting that the IT resources needed to build and
maintain such interfaces may be less available to rural
facilities, on average.

Finally, although electronic reporting of data to public
health agencies has improved over the past decade,
health IT stakeholders interviewed recently expressed
that current public health reporting systems, such as
CalREDIE and CURES, require substantial updates
and standardization to meet future expanded report-
ing requirements and data exchange, such as those
articulated by AB 133.°

Foremost, about 45% of the responding
hospitals indicated that public health
agencies lacked the capacity to electronically
receive immunization data, lab results,
surveillance data, case reports, and other
information typically collected for public
health purposes.

 

California Health Care Foundation

www.chcf.org 8
The HITECH funding and meaningful
use programs did little to increase EHR
adoption and electronic data exchange
for skilled nursing facilities, substance
use disorder facilities, and nonmedical
social service agencies. This leaves a
notable gap in achieving the objectives
of the CalAIM program, which the state
may need to address.

The Medicare and Medicaid meaningful use programs
and ancillary funding vehicles significantly increased
EHR adoption and HIE capabilities among "eligible"
providers in California - hospitals, physicians, some
professionals, and certain other clinicians. However,
other types of facilities and professionals involved in
maintaining and restoring the health of Californians
were not eligible for the incentive funding and techni-
cal assistance provided by HITECH. Further, the health
IT systems typically used by these types of organiza-
tions were not required to implement any particular
exchange capabilities or standards, unlike the EHRs
that were certified for use by eligible hospitals and
eligible professionals under the HITECH meaningful
use programs. At least partially owing to these limita-
tions of the HITECH programs, the data collected for
the HIT Landscape Assessment indicate that "noneli-
gible" organizations, including skilled nursing facilities
(SNFs), substance use disorder treatment facilities,
and nonmedical public welfare agencies, now lag
behind eligible provider organizations in their adop-
tion of EHRs and in their electronic sharing of patient
information. Figure 7 illustrates the differential in EHR
adoption rates among health care settings, based on
available data.

Figure 7. EHR Adoption Rates in California,
by Health Care Facility Type

 

Hospitals (2018)

96%

Office-Based Physicians (2017)

Thea

Skilled Nursing Facilities (2019)

32%

Substance Abuse Treatment Facilities (2017)

bl

*Percentage that use exclusively electronic means to store and maintain health
records only, not full EHR adoption.

Source: Julia Adler-Milstein et al., California Health IT Landscape Assessment:
Final Report - February 2022, California Dept. of Health Care Services.

EHR Use at Skilled Nursing Facilities

Although no definitive data exist on the adoption of
EHRs among SNFs in California, only 32% of the SNFs
responding to a 2019 survey reported that their "physi-
cian documentation" was stored within the SNF's EHR
(as opposed to within attending physicians' office-
based EHRs or within the EHRs of affiliated hospitals).
At the same time, 22% to 56% of the SNF survey
respondents indicated that they perform various infor-
mation management functions using "fully electronic"
methods, including documenting clinical notes (39%),
viewing lab results (28%), entering medication orders
(56%), and receiving decision support for medica-
tions (33%). However, many of these functions may
be provided by electronic systems that support only
those single capabilities or a handful of capabilities,
rather than fully functional EHRs. More recently (and
anecdotally), a leader of the California Association of
Health Facilities, an industry trade group for SNFs,
estimated in a late-2021 interview that "over half [of
the association members] probably have a solid EHR,
others have bits and pieces."

 

An Assessment of the California Health Information Technology Landscape in 2022: Summary of Key Findings 9
Data Exchange by Skilled Nursing Facilities
When patients are admitted to SNFs, their clinical
data are seldom made available via electronic docu-
ments and messages sent from the discharging facility.
Among the California SNFs that reported having an
EHR in the 2019 survey, less than 30% indicated that
they have interoperability with their local hospital
EHR(s) (which is, nevertheless, better than the national
average of 16%).

In fact, a majority of the SNFs responded that they
still use nonelectronic methods "always or often" to
receive information about incoming patients, includ-
ing phone conversations with the discharging hospital
(71% of respondents), faxes sent by the discharging
hospital (65% of respondents), and records physi-
cally brought in by the patient or a caregiver (65% of
respondents) (see Figure 8). Although 40% to 50% of
the respondents did indicate that they always or often
use an "online referral platform" or "online portal"
to access data for incoming patients (an improve-
ment over nonelectronic means), this method may not
provide the capability to import patients' discharge
medications, discharge diagnoses, and recent lab
values into the SNFs' own information systems in a
structured and coded form.

Figure 8. Methods Used by California SNFs to Receive
Patient Information from Discharging Providers,
by Frequency, 2019

 

Phone Conversation with Provider Staff
Abs
19%

10%

Records Faxed or eFaxed
65%
19%
16%

Records Brought in by Patient, Caregiver, or EMS
oho)
uh
16%

Shared Online Referral Platform
TSS
ha
32%

Online Portal to View Provider's Discharge Document
Ry
16%

55%

Shared EMR with Provider

EID
2x

B® Always 1) Sometimes MM Rarely/Never

 

California Health Care Foundation

www.chcf.org 10
EHR Use at Substance Use Disorder
Treatment Facilities

The most recent survey of health IT use at substance
use disorder treatment (SUDT) facilities was in 2017,
and it did not directly ascertain the proportion of facili-
ties that use EHRs. However, the survey respondents
did indicate which information management tasks were
performed at their facilities using methods that were
"exclusively electronic," "
with paper methods," or "exclusively paper-based."
Only 18% of these respondents indicated that they
used "exclusively electronic" methods to store and
maintain health records, which may be a suitable proxy
for the proportion of SUDT facilities that use EHRs. A
higher percentage of respondents reported that their
facilities used exclusively electronic methods for vari-
ous individual information management tasks, such as
assessments (29%), progress monitoring (35%), and
treatment plans (36%). However, given the partly or
fully paper-based methods used to store and maintain
health records at the same facilities, these methods
for individual tasks likely entail limited-purpose tools
rather than fully functional EHRs.

electronic in combination

Data Exchange by Substance Use

Disorder Facilities

Although quantitative data were not available regard-
ing SUDT facilities' use of electronic methods to
exchange patient data, representatives of the facilities'
trade association did express anecdotally a general
frustration in the "lack of willingness from primary
care, Medicaid managed plans, and HIEs to engage in
data sharing with behavioral health systems."

Data Exchange by Other Facilities

Frustration regarding electronic data sharing was also
reported in recent interviews by representatives of
other facilities not eligible for HITECH funding. The
comments of these stakeholders were consistent with
the quantitative survey findings for SNFs and SUDT
facilities. A representative of county mental health ser-
vice providers shared:

"There's a lot of management that we do
[for patients with mental illness]. So the lack
of willingness for primary care or Medicaid
managed care plans to share data with us is
really challenging."

A representative of public welfare agencies stated:

"There is room to try to make sure our systems
can better match things up to assess how we
are doing in terms of things like, are kids in
foster care being seen by health providers?
Are they getting preventative care? Are they
getting mental health assessments? Are they
getting treatment as they need? The existing
data systems don't make it easy to answer
that question."

The state's CalAIM initiative has established ambitious
goals for the sharing of health, social services, housing,
and criminal justice information, records, and other
data with the state, Medi-Cal managed care plans,
health care providers, social services organizations,
care coordination, and case management teams. As
such, the state will need to address the remaining gaps
in EHR adoption and electronic data sharing among
SNFs, behavioral health facilities, social service agen-
cies, and other noneligible entities that did not benefit
from the HITECH and meaningful use programs over
the preceding decade.

 

An Assessment of the California Health Information Technology Landscape in 2022: Summary of Key Findings 11
Further policy measures and changes
to regulations are required to facilitate
and promote the electronic data
exchange needed for state initiatives

such as CalAIM.

Beyond potential funding for adopting EHRs and for
implementing the technical mechanisms to share data
electronically, stakeholders interviewed for the Health
IT Landscape Assessment also supported additional
state policies they felt are needed to achieve the data
sharing goals of the CalAIM initiative. These policies
include regulatory requirements, financial incentives,
or both for provider organizations to consistently
share data during transitions of care. These measures
are required to overcome remaining inertia in data
sharing, such as that characterized by one stakeholder
from a SNF:

"Hospitals only care if you take their patients.
If you don't get all the information, they're
not super worried about it . . . it's very
frustrating when you have patients that are
struggling, and there's information we know
we should have [but don't]."

Further, regulatory "safe harbors" may be needed for
required data sharing. For example, nonmedical social
service organizations reported barriers to useful data
sharing arising from state and federal confidentiality
laws, including the HIPAA (Health Insurance Portability
and Accountability Act) prohibition on medical pro-
viders sharing patient data with noncovered entities.
If possible, state-level action (or state-level guidance
of federal action) may be required to relax prohibitive
privacy constraints while preserving privacy.

In addition to policies and incentives, technical assis-
tance was responsible for much of the success in
adoption, particularly in settings that lacked finan-
cial and technical resources. The value of technical
assistance will also be applicable when considering
CalAIM's ambitious goals. As one stakeholder wrote:

"It was not only the dollars that were
associated with HITECH, but it was the
technical assistance that came with HITECH
that was really the dual edge there. That
you not only provided the funding source
for the IT system investments, but provided
ongoing technical assistance is really
critical and crucial, particularly for smaller
entities - that was probably a crucial part
of the equation."

 

California Health Care Foundation

www.chcf.org 12
Finally, the state may need to designate specific exist-
ing interoperability standards, or even extend existing
standards to accommodate new use cases, to sup-
port the objectives of the California Data Exchange
Framework as a vehicle to facilitate the CalAIM pro-
gram. As one stakeholder summarized:

"With the Data Exchange Framework, | think
it's great that we're getting more specific
into how we think about the standards and
particularly federal standards, and also
getting clarity on what is and not allowable
for exchange."

Conclusion

Data from the past 10 years show a progressive and
substantial rise in health IT use and health care data
exchange among hospitals and physicians in California,
largely owing to federal and state incentive funding.
The electronic exchange of data between health care
provider organizations and public health agencies also
increased during this time. However, significant work
remains to achieve the same levels of health IT use
and data exchange among other organizations that
did not receive HITECH incentive funding, including
skilled nursing facilities, behavioral health providers,
and nonmedical social service agencies. Work also
remains to further expand the frequency and value of
electronic data sharing among provider organizations,
as well as to further modernize statewide information
systems for the collection and sharing of public health
data. This ongoing work will be critical to achieving
the goals of the CalAIM program and other planned
improvements to California's health care delivery
system.

About the Author

Walter Sujansky, MD, PhD, is the principal consultant at
Sujansky & Associates, a California-based consulting
firm that specializes in the analysis and design of EHRs,
disease registries, and solutions for health information
exchange. Dr. Sujansky is also an adjunct professor at
the Center for Biomedical Informatics Research at the
Stanford School of Medicine, and an expert health IT
consultant for litigation involving intellectual property
and medical malpractice.

About the Foundation

The California Health Care Foundation is dedicated
to advancing meaningful, measurable improvements
in the way the health care delivery system provides
care to the people of California, particularly those
with low incomes and those whose needs are not
well served by the status quo. We work to ensure that
people have access to the care they need, when they
need it, at a price they can afford.

CHCF informs policymakers and industry leaders,
invests in ideas and innovations, and connects with
changemakers to create a more responsive, patient-
centered health care system.

 

Endnotes

1. Julia Adler-Milstein et al., California Health IT Landscape
Assessment: Final Report - February 2022, California Dept.
of Health Care Services (DHCS).

2. "CalAIM," DHCS.

3. "Data Exchange Framework," California Health and Human
Services Agency.

4. The AHA survey asked a number of specific questions about
each hospital's clinical information technology. Responses to the
questions determined whether the hospital's EHR had "basic"
or "comprehensive" capabilities as defined by Jha et al. (see
Ashish K. Jha et al., "Use of Electronic Health Records in
US Hospitals," New England Journal of Medicine 360, no. 16
(Apr. 16, 2009): 1628-38).

5. See "Promoting Interoperability Programs," Centers for
Medicare & Medicaid Services, last modified May 16, 2022.

6. See Health Omnibus Trailer Bill - AB 133 (PDF), County Health
Executives Association of California.

 

An Assessment of the California Health Information Technology Landscape in 2022: Summary of Key Findings 13