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Much of the action on health care continues to occur at state and local levels, with support from the federal government and national and local philanthropies. Many states begin by forming a commission to develop an action plan for HIT and, most significantly, bring together the various interested parties. Since 2005, almost one-third (17) of the states have created such commissions. The next stage for many states may be a pilot project, where various aspects of HIT—from e-prescribing to electronic health records systems—are tested. The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicaid and Medicare Services (CMS) have funded grant programs to states and localities.  The grants are used to experiment with different approaches at the same time that they create opportunities for various groups to build trust by working together. This all has been further accelerated by the passage of the 2009 stimulus bill allocating $19 billion over the next few years at all levels of government for digitalizing all health records.  

In 2007, some states have staked out ambitious efforts to accelerate Health IT adoption.  Missouri is implementing CyberAccess, an EHR system for recipients in its Medicaid program. CyberAccess is a Web-based utility that will allow physicians to view patients’ medical history, e-prescribe, obtain medical prior authorization and receive clinical decision alerts. Missouri hopes the program will be the foundation for an EHR system for all patients in the state.  While, Minnesota has set two HIT implementation deadlines for those involved with health care. Minnesota is the first state to require all health care payers and providers to submit claims and eligibility transactions in a common electronic format, setting a 2009 deadline for converting to this system. Minnesota also will require all hospitals and health care providers to have an interoperable electronic health records system in place by 2015. The state intends to follow federal standards (that are being developed) as it sets interoperability standards to be used by 2009.  

The process of addressing Health Information Technology began in earnest at the Federal level under President George W. Bush, and the passage of the 2009 Stimulus Bill, reiterates the Democratic Congress’ and White House’s support for expanding Health IT as a way to limit medical mistakes and avoid bad health interactions. The divides in support and opposition for expanding health IT at the state level comes in two forms. Civil libertarians have expressed concern about how personal health information will be used and misused. But the overarching concerns attached to a complete rollout of health IT and digital health records seem to be breaking along rural-urban lines. Folks in the cities and suburbs generally have broadband service, while people in more rural places; generally have inferior internet access. The question of a digital divide, more than any one factor seems to be in large measure driving support or opposition to the effort to move towards digital records. Infrastructure issues have historically been a shared concern Local, State and Federal. (Think about roads or water systems as examples). In part, this is why expanding broadband service is in the ’09 stimulus bill. Money spent will take the shape of direct grants to the states and local government to lay fiber optic lines. In doing so, working to bridge the rural/urban divide on health IT.

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