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Nationwide Health Information Network (NHIN) Workforce Study: Final Report

Publication Date
Sep 18, 2007

Submitted to

Assistant Secretary for Planning and Evaluation Office of the Secretary U.S. Department of Health and Human Services Washington, DC

Submitted by:
Altarum Institute Ann Arbor, MI
NHII Advisors Arlington, VA


Executive Summary

For the past several years, the nation has been working to improve health care through the widespread implementation of electronic healnth records. One clear prerequisite for accomplishing this goal is the availability of a trained workforce to implement the developing Nationwide Health Information Network (NHIN). While it is generally acknowledged that the nation does not have a sufficient number of trained specialists for this purpose, no prior studies have produced any quantitative estimates of the workforce requirements. Accordingly, the current research was designed to further our understanding of NHIN workforce issues by collecting, assessing, and analyzing existing knowledge and data in this domain with the objective of producing an initial estimate of the number of people needed.

This study gathered information through a series of four focus groups, five site visits, and direct communications with health information technology (HIT) vendors. The anticipated NHIN work was divided into three separate categories of activities for the purpose of assessing workforce:

  1. electronic health records (EHRs) in physician offices;
  2. EHRs in hospitals and other health care institutions; and
  3. the health information infrastructure (HII) required in communities to link the various sources of records so that each patient’s complete electronic record could be available.

Assuming a 5-year time frame for NHIN implementation, results indicated that 7,600 (+/- 3,700) specialists are needed for installation of EHRs for the approximately 400,000 practicing physicians who do not have them already. For the hospitals needing EHRs (about 4,000), approximately 28,600 specialists are needed. Finally, about 420 people are needed to build the HII systems in communities to interconnect all these other systems. These data represent the first ever quantitative estimates of the workforce needed to implement the NHIN.

These estimates should be considered preliminary and imprecise as they are based on a very small number of reports: eight for physician EHRs, four for hospitals (no data were available for other types of health care institutions), and two for communities. Furthermore, since all reported data was retrospective, the various estimates are based on information collected inconsistently at different times and under varying circumstances. Insufficient information was available to be able to characterize meaningfully the different types of personnel needed, although at least 15 different job titles were identified and defined. There was also inadequate information to allow workforce estimates for different architectures for the three major activities, despite general agreement from the expert panels that differences in architecture may have a significant impact on the personnel needs. Similarly, there was not enough data to assess or categorize the impact of size of practice or institution on workforce. However, there were some indications that the personnel requirements per physician are higher for smaller physician offices (three physicians or less). Also, the workforce data relates only to installation of systems; ongoing support and maintenance were specifically excluded. Finally, it is notable that there is no available data about the current number of specialists working in the three areas, so it is not clear whether these estimates indicate a shortage of personnel.

Further research is needed to confirm and refine these estimates, as well as overcome the limitations of these results. Nevertheless, these first-ever quantitative estimates of the workforce needed for NHIN implementation will inform such additional studies, lead to an improved understanding of this important domain, and ultimately help ensure that adequate numbers of personnel are available for this critical work.


In 1991, the Institute of Medicine (IOM) called the electronic health record (EHR) “an essential technology for patient care.” Level Descriptor Minimum Average Maximum PHYSICIAN OFFICE EHRs FTE days per physician 12.00812 23.68577 35.36343   FTE years per physician 0.04803 0.09474 0.14145   TOTAL FTEs NEEDED 3,843 7,579 11,316 HOSPITAL EHRs Avg Implementation Time NA 17.3 NA   N Implementation Cycles NA 3 NA   FTE Years per hospital NA 21.46 NA   TOTAL FTEs NEEDED NA 28,620 NA COMMUNITY HEALTH NETWORKS Avg Implementation Time NA 15 NA   N Implementation Cycles NA 4 NA   FTE Years per community NA 5.55 NA   TOTAL FTEs NEEDED NA 416 NA

Figure 1. NHIN Workforce Estimates Versus Time Available for NHIN Implementation

Graph: NHIN Workforce versus Time Span. Graph has one line each for PHYSICIAN OFFICE EHRs, Hospital EHRs, and Community Health Networks showing rough workforce needs for year 2 through 8. Hospitals have the largest demand but drop significantly for each year from roughly 87,000 in year two to 19,000 in year eight. Physicians offices are shown making a smooth decline from 20,000 to roughly 6 thousand, and Community Health is shown as a relatively flat but declining line near the bottom of the scale.

References Accessed February 18, 2007. .  Accessed August 12, 2006. Accessed August 12, 2006.


We wish to acknowledge the project officer for this study:

Suzie Burke-Bebee, MSIS, MS, RN
Senior Health Informatician
Office of the Assistant Secretary for Planning and Evaluation
Office of the Secretary
Department of Health and Human Services

The following people contributed to this report as members of technical expert panels or through individual consultations. We appreciate their time and effort in providing feedback and insight into this study. Douglas A. Abel, MBA, Vice President, Chief Information Officer, Anne Arundel Medical System, Annapolis, MD
Gregory Almond, MD, MPH, Chairman, Emergency Medicine, New York Medical College, New York, NY
Gail Arnett, Healthcare Information and Management Systems Society, Electronic Health Records Vendor Association (EHRVA), Chicago, IL
Peter Basch, MD, Medical Director, eHealth, MedStar Health, Washington, DC
Jacki Bebb, Special Projects Coordinator and Medical Records Administration Specialist, Health Data Informatics, Veterans Health Affairs, Office of Information, Department of Veterans Affairs, Washington, DC
A. John Blair III, MD, President, Chief Executive Officer, Taconic IPA, Fishkill, NY
Meryl Bloomrosen, Associate Vice President, American Medical Informatics Association, Bethesda, MD
Don E. Detmer, MD, MA, President, Chief Executive Officer, American Medical Informatics Association, Bethesda, MD
Claire Dixon-Lee, PhD, Vice President, Education and Accreditation, American Health Information Management Association, Chicago, IL
Sharon Donnelly, MS, Healthcare Redesign, Health Insight, Salt Lake City, Utah
Thomas M. Fritz, MA, MPH, Chief Executive Officer, Inland Northwest Health Services, Spokane, WA
David Gans, MSHA, Vice President, Practice Managment Resources, Medical Group Management Association, Englewood, CO
LCDR Ron Gimbel, PhD, Assistant Professor, Interim Executive Director, Uniformed Services University of the Health Sciences, Bethesda, MD
Lori L. Hack, MBA, Director, Government Relations and Policy, California Regional Health Information Organization, San Francisco, CA
John Hansmann, MSIE, Region Manager, Management Engineering, Intermountain Healthcare, Salt Lake City, Utah
James Hereford, MD, MSc, Executive Vice President, Strategic Services and Quality, Group Health Cooperative of Puget Sound, Seattle, WA
Ronda Hughes, PhD, MHS, RN, Senior Health Scientist, Center for Primary Care, Prevention and Clinical Partnerships, Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
Kendall D. Hunter, MPP, MBA, Chief Administrative Officer, Mid-Atlantic States, Kaiser Permanente, Rockville, MD
Liesa Jenkins, MA, Executive Director, CareSpark, Kingsport, TN
Stasia Kahn, MD, Vice President, Northern Illinois Physicians for Connectivity, Glen Ellyn, IL
Gina King, MPP, Healthcare Industry Lead, Business Relations Group, Employment and Training Administration, Department of Labor, Washington, DC
Linda Kloss, MA, Chief Executive Officer, American Health Information Management Association, Chicago, IL
Thomas M. Leary, Director of Federal Affairs, Healthcare Information and Management Systems Society, Chicago, IL
Mark Leavitt, MD, PhD, Chairman, Certification Commission for Health Information Technology, Chicago, IL
Stephen R. Levinson, MD, ASA, LLC, Easton, CT
David McCallie Jr., MD, Vice President, Medical Informatics, Cerner Corporation, Kansas City, MO
Rick MacCornack, PhD, Chief Systems Integration Officer, Northwest Physicians Network, Tacoma, WA
Jay McCutcheon, MBA, Principal, Health Network Systems, Michiana Health Information Network, South Bend, IN
Blackford Middleton, MD, MPH, MSc, Corporate Director, Clinical Informatics Research and Development, Partners Healthcare Systems, Chairman, Center for IT Leadership, Assistant Professor of Medicine, Harvard Medical School, Boston, MA
Michael Millman, PhD, MPH, Director, Research and Data Policy Group, Office of Planning and Evaluation, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD
James R. Morrow, MD, Vice President, Chief Information Officer, North Fulton Family Medicine, Cummings, GA
Nancy Nelson, RN, CMPE, Chief Administration Officer, Cardiology of Tulsa Incorporated, Tulsa, OK
Angela Nicholas, MD, Vice President, Chief Information Officer, Information Technology, Susquehanna Health, Williamsport, PA
Elaine Olson, CMT, Executive Director, Medical Transcription Industry Association, Chicago, IL
Will Ross, Project Manager, Mendocino Informatics, Ukiah, CA
Jan Root, PhD, Assistant Executive Director, Utah Health Information Network, Salt Lake City, UT
Timothy Schoener, Administrative Director, Information Technology, Susquehanna Health, Williamsport, PA
Carla Smith, FHIMSS, Executive Vice President, Health Information and Management Systems Society, Chicago, IL
Michael Spain, MD, MBA, Chief Executive Officer, Cardiology of Tulsa Incorporated, Tulsa, OK
Walter Suarez, MD, President, Chief Executive Officer, Institute for Health Insurance Portability and Accountability Act/Health Information Technology Education and Research, Alexandria, VA
William Stead, MD, Associate Vice Chancellor, Chief Informatics Officer, Vanderbilt University Medical Center, Nashville, TN
Captain David Taylor, MSH, RN, National Informatics Consultant, United States Public Health Service, Office of Information Technology, Indian Health Service, Department of Health and Human Services, Sylva, NC
Robert M. Tennant, MA, Senior Policy Advisor, Medical Group Management Association, Washington, DC
Jessica Townsend, MAHCA, Public Health Analyst, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD
Charlene S. Underwood, MBA, Director, Government and Industry Affairs, Siemens Medical Solutions, Malvern, PA
Phelgar Washington, MD, Washington Eye Center, Indianapolis, IN
Charles Webster, MD, MSIE, Chief Medical Informatics Officer, JMJ Technologies, Atlanta, GA

We thank the following individuals, physician practices, and health information exchanges for hosting site visits for this study:

J. Marc Overhage, MD, PhD
President, Chief Executive Officer, Indiana Health Information Exchange
Director of Medical Informatics, Regenstrief Institute
Indianapolis, IN

J. Michael Leahy, MBA
Chief Executive Officer
Oregon Community Health Information Network
Portland, OR

Marc Pierson, MD
Vice President, Clinical Information, Special Projects, and Medical Affairs Administration
Saint Joseph Hospital, Whatcom Region, Peace Health
Bellingham, WA

Denni McColm, MBA
Chief Information Officer
Citizens Memorial Healthcare
Bolivar, MO

Thomas Ehrlich, MD
Chairman, Physician Information Technology
Fairfax Family Practice
Fairfax, VA

This research project was performed for the Office of the Assistant Secretary for Planning and Evaluation (ASPE), United States Department of Health and Human Services, under contract number HHSP23320045014XI and task order number HHSP233200600006T. Principal Investigator: William A. Yasnoff, MD, PhD, NHII Advisors, Arlington, VA.