Toward a Nationwide Health Information

In April 2004, President Bush’s Executive Order No.13335 (1) established the Office of National Coordinator for Health Information Technology (ONC) at the Department of Health and Human Services (HHS) to coordinate health information technology adoption (2).The vision is to develop a Nationwide Health Information Network (NHIN or NwHIN) of regional Health Information Exchanges (HIEs) connecting electronic health record systems (EHR-Ss) deployed in clinical practices with each other and with other systems required to support the healthcare system.

The 2008-2012 ONC Coordinated Federal HIT Strategic Plan (3) focused on two goals: Patient-focused Healthcare to enable the transformation to higher quality, more cost-efficient health care through electronic health information access and use by care providers, and by patients and their designees; and Population Health to enable the appropriate, authorized, and timely access and use of electronic health information to benefit Public Health, biomedical research, quality improvement and emergency preparedness. The Plan is based on four objectives: Collaborative GovernanceHIT AdoptionPrivacy and Security and Interoperability, i.e., the ability of different information systems to communicate (exchange) data accurately, effectively and consistently (4).

The Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act of 2009 (ARRA (5)), is aimed at advancing HIT by supporting the adoption and “meaningful use” of certified electronic health record systems through incentive payments to eligible professionals (physicians and hospitals) (6). Recipients of these incentive payments may be required to report clinical, and quality measures to demonstrate accountability for achieving the meaningful use parameters promised. In addition, the EHR-S technology adopted under these provisions must be compatible with State or Federal administrative management systems (7). The updated Federal Health IT Strategic Plan defines national goals for HIT adoption through 2015 (8).

Public health data systems are created to support specific needs of certain program areas i.e., newborn screening, birth defects, immunization, communicable disease surveillance, injury prevention, bioterrorism, etc. Systems maintained by these programs are populated with data reported by health care providers usually using paper-forms. These “silo”-type public health data systems may deploy certain software products that are often custom-made to serve particular programmatic needs and are not interoperable across health departments. Lack of integration and interoperability across public health program systems leads to the inefficient use of resources and frustration among families and providers asked to provide the same information on multiple forms of varying formats to various programs. The current systems do not allow easy aggregation of patient’s information to provide real-time data back to the provider’s office and to conduct research.

Because of the automation of clinical data – inpatient and increasingly outpatient – via the EHR systems (EHR-S), public health programs stand at the threshold of change in the way in which they can gather and analyze programmatic data. The EHR is a pivotal instrument in integrating clinical and public health data systems – EHR-PH systems, so public health authorities will have reliable, real time access to patient data to support health policy decisions for disease prevention interventions. The EHR-based bi-directional data interchange between clinical and public health settings will improve care coordination, healthcare resources allocation and healthcare delivery planning for better and safer care. The integrated EHR-PH systems will become the backbone of a National Health Information Network and regional health information exchanges (RHIEs).

To facilitate the development of interoperable EHR-PH systems there is a need for standardization of health information exchanges across clinical and public health enterprise. The national Health Information Technology Standards Panel (HITSP) (9) identified the following categories of standards for system interoperability:

  1. Data content standards, i.e., vocabularies and terminology standards
  2. Information content standards, i.e., Reference Information Models (RIMs)
  3. Information exchange standards, e.g., messaging standards
  4. Identifier standards, e.g., National Provider Identifier (NPI) standard
  5. Privacy and security standards
  6. Functional standards, i.e., workflow/dataflow standards
  7. Other, e.g., information technology infrastructure standards.


  1. National Archives and Records Administration. Federal Register. Executive Order 13335 – Incentives for the use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator. URL’s: and
    URL:  Last accessed March 05, 2009
  2. Thompson TG and Brailer DJ. The Decade of Heath Information Technology to Deliver Consumer-centric and Information-rich Health Care. Framework for Strategic Action. US DHHS, July 21, 2004. URL:
  3. Department of Health and Human Services. The ONC Coordinated Federal Health Information technology Strategic Plan. June 3, 2008. URL:
  4. Department of Health and Human Services. Office of National Coordinator for Health Information Technology.  Consensus Conventions for the Use of Key HIT Terms Project. 2008
  5. The American Recovery and Reinvestment Act. 2009. URL:
  6. Health Information Technology for Economic and Clinical Health (HITECH) Act. Federal Register/ Vol. 74, No. 101/ Thursday, May 28,
    2009/ Notices: p.25550-25552.
  7. Health Information Technology Policy Committee (a Federal Advisory Committee). URL:
  8. HHS Office of National Coordinator of Health Information Technology (ONC). Federal Health Information Technology Strategic Plan: 2011-2015. URL:
  9. Health Information Technology Standards Panel (HITSP). American National Standards Institute (ANSI). URL:
  10. Health Information Technology Policy Committee. URL:
  11. Health Information Technology Standards Committee. URL:
  12. American Health Information Community (AHIC). URL:
  13. Health Level Seven (HL7). URL:
  14. International Health Terminology Standards Development Organization (IHTSDO). URL: former Systematized Nomenclature of Medicine – Clinical Terms (SNOMED). URL:{actionForm.contentReference}=snomed%2Fsnomed_ct.html&_state=maximized&_pageLabel=cntvwr
  15. Logical Observation Identifiers Names and Codes (LOINC). URL:
  16. The Accredited Standards Committee (ASC) X12. URL:
  17. Integrating the Healthcare Enterprise (IHE). URL:
  18. Health Information Technology Standards Panel (HITSP). URL:
  19. The Office of the National Coordinator for Health Information Technology (ONC). URL:
  20. Public Health Data Standards Consortium (PHDSC). Web Resource Center. Health Information Technology Standards. On-line Module. URL: