National Association of Attorneys General

National Association of Attorneys General National Association of Attorneys General

Attorneys General and the State Alliance for eHealth

Paula Cotter, Environment Project Director and Chief Counsel

Technological development has profoundly changed the health care community in the last 15 years. Computerized health information has become more common, and the Internet has made it more accessible. The systematic use of computer science and information science has become known as health informatics. The term “eHealth” has also been used to describe “health services and information delivered or enhanced through the Internet and related technologies.”[1] The term includes a wide variety of activities such as online billing, e-prescribing, and telemedicine, all of which involve use of information and health services. The overarching challenge in each area of eHealth is to promote the exchange of information (called interoperability) and protect the individuals whose information is being transferred, stored and protect their privacy.

In response to the changes in technology, the federal Department of Health and Human Services spearheaded an initiative, the Nationwide Health Information Network (NHIN)[2]. NHIN serves as a “network of networks,” linking state and regional health information electronic health information exchanges. The long-term goal of the NHIN is to provide continuous real-time access to patient health care information as needed.

The State Alliance for eHealth[3] was created to facilitate the NHIN by examining aspects of eHealth that are unique to states. The State Alliance was formed by the National Governors Association’s Center for Best Practices, under a contract with the Department of Health and Human Services. There are 19 members of the State Alliance for eHealth. Governors Phil Bredesen (Tennessee) and Jim Douglas (Vermont) are co-chairs of the Alliance; there are also three state legislators, two former governors, two insurance commissioners, and Attorneys General Steve Carter (Indiana) and Hardy Myers (Oregon), all voting members. The Alliance also includes a non-voting contingent of eight advisory members, who are from the private sector, academia, and state government health policy offices.

During the first phase of its existence, the State Alliance identified three primary goals, each associated with a Task Force that consists of stakeholders at the state level: the Health Information Protection Task Force, the Health Care Practice Task Force, and the Health Information Communication and Data Exchange Taskforce. The task forces develop reports examining the issues within their purview, and make recommendations to the Alliance as a whole. The reports[4] may be found online as part of the website established to inform the public about the work and findings of the State Alliance. The State Alliance has also published Accelerating Progress: Using Health Information Technology and Electronic Health Information Exchange to Improve Care, summarizing the “testimony, deliberations, research and other activities” that the State Alliance for eHealth conducted or solicited during its first year.

Accelerating Progress includes six recommendations of two are perhaps most relevant to Attorneys General. First, the Alliance recommends that states address health information privacy and security. Existing state statutes and systems are quite variable in their approaches and their substantive requirements on privacy protection. For instance, some laws were clearly designed for a paper-based system, and are ill-adapted to electronic health information—it is difficult to say what an “original” document would be in the context of an electronic record. Within a state, an individual’s information may be treated differently. Moreover, the current state of technology allows information to move between states much more freely than it did in the past, which can lead to confusion about what is required at the level of hospital, lab, or doctor’s office.

The State Alliance developed two broad strategies as part of the recommendation to address health information privacy and security. First, the report suggests that states “[c]onsolidate and update relevant privacy and security laws to better respond to consumer protection needs in an electronic exchange environment.” The report identifies several states’ efforts in this area. Some of them are mere codifications; but others represent an effort to address the electronic exchange of health information. For instance, Minnesota’s revised statutory structure is part of a broader health reform package enacted in spring of 2008. The new legislation will require e-prescribing by 2011, and will mandate interoperable health records by 2015. The State Alliance does not endorse any particular state’s approach, but does clearly recommend that states re-examine their privacy and security laws.

The second strategy recommended by the State Alliance is that states “[E]ducate leaders and support efforts to reduce variation of state privacy requirements while ensuring appropriate consumer protections.” While acknowledging the difficulties of real progress outside a federal review of privacy and security provisions, the Alliance recommends that each state foster education of the public and policy-makers about the specific challenges associated with their jurisdictions.

The other recommendation for state Attorneys General is for states to streamline the licensure process to facilitate cross-state eHealth. In sum, the problem is that current licensing for medical professionals was developed long before the advent of the internet, telemedicine, or even phone-based practice. Each state’s requirements and process are different, and many questions arise when someone licensed in one jurisdiction has a patient in another. The State Alliance looked closely at three medical professions, nurses, physicians and pharmacists, and developed a series of strategies to help states implement that recommendation. The eight strategies identified by the Alliance are:

To streamline the licensure application process…

  • Direct each state health professional board to develop or adopt common core licensure applications.
  • Direct each state health professional board to implement and promote the use of online licensure applications.

To streamline the licensure credentialing process…

  • Direct each state health professional board to work with its counterparts in other states to develop a nationwide core set of credentialing parameters.
  • Direct each health professional board to utilize a single, centrally coordinated credential verification organization (CVO) to conduct primary source verifications.
  • Direct each state health professional board to require state and federal criminal background checks from all applicants seeking an initial state license.

To streamline the licensure structure…

  • Direct the state medical and pharmacy boards to individually participate in a collaborative effort with their respective state board counterparts to establish a process that ensures licensure recognition by other states.
  • Direct the state nursing board to participate in the Nurse Licensure Compact
  • States should pursue standardization of the regulatory framework for each field of advanced practice nursing.

The National Association of Attorneys General has undertaken to support aspects of the State Alliance for eHealth and its work. To this purpose, NAAG has presented a series of webinars covering basic points of three aspects of eHealth. On May 21, Professor Joy Pritts of Georgetown Law assisted in presenting an introduction to eHealth and electronic privacy issues. On June 10, a representative of Sure-Scripts/Rx-Hub, a health care infrastructure that facilitates electronic communications between pharmacists and physicians, spoke on the development and history of e-prescribing. The final webinar was scheduled for Wednesday, October 22; its subject was interstate issues, with a focus on licensure issues. The materials from all the webinars will be posted on the NAAG website.

1 This definition is derived from an influential 2001 essay in the Journal of Medical Internet Research, see “What is e-health?” G. Eysenbach,

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