Mr. Chairman and Members of the Subcommittee: Good morning. My name is John Glaser. I am the Vice President and Chief Information Officer of Partners HealthCare. Partners HealthCare is an integrated system of medical care whose members include the Brigham and Women’s Hospital, the Massachusetts General Hospital, community hospitals, health centers, physician practices and visiting nurses. Over the course of a year, Partners physicians and nurses will deliver care in 4,000,000 outpatient visits and 160,000 admissions.

I am also the President of the Board of the eHealth Initiative (eHI). The eHealth Initiative represents the multiple and diverse stakeholders in healthcare and health information -- consumer and patient groups, employers and purchasers, health plans, hospitals, laboratories, practicing clinicians, public health agencies, HIT suppliers and others-- dedicated to driving improvement in the quality, safety, and efficiency of healthcare through information and information technology.

Implementation of Electronic Medical Records (EMRs) For the past 18 years, I have had the overall responsibility for the implementation of electronic health records (EHRs) at the Brigham and Women’s Hospital and then Partners HealthCare.

During this time, we have implemented computerized provider order entry (CPOE) at Brigham and Women’s Hospital, the Massachusetts General Hospital, the Faulkner Hospital and the Dana Farber Cancer Institute. Physicians use CPOE to enter 30,000 clinical orders a day. Medical logic is applied to the order to ensure, for example, that the requested medication is safe or the radiology procedure being ordered is appropriate. Implementation across all our community hospitals will be completed by the end of next year.

Currently, we have 2,600 Partners physician users of our electronic medical record (EMR) and over the course of the next four years, we will add an additional 2,000 physicians. Our implementation efforts are currently focused on physicians in our community practices.

We have applied telemedicine to offer specialist second opinions to patients around the country and the world. And we support the home monitoring of patients with chronic diseases and recent surgical patients.

We provide technologies to enable patients to converse with their physician and access their medical record. Our base of 25,000 patients is growing at a rate of 7,000 new patients a year.

More recently, we have begun to invest in the information technology necessary to help our physician researchers understand the genomic basis of disease. These systems help the researcher, for example, to determine why most asthma patients respond to steroid therapy, while 10 percent do not.

In collaboration with regional providers and payers, we have recently begun to integrate our EHRs with those of other providers across the Commonwealth of Massachusetts.

Health Information Technology and Patient Safety Based on our extensive experience, and those of others, there is no question that information technology, when thoughtfully applied, can be leveraged to effect significant improvements in the safety, quality and efficiency of the care that we deliver.

Studies of CPOE with decision support, at the Brigham and Women’s Hospital, show that medication errors were reduced by 80 percent and serious medication errors were reduced by 55 percent

Additional studies of CPOE show decreases in the time spent by patients in the hospital, significant reductions in inappropriate antibiotic use, increased appropriateness of medication and radiology procedure orders and significantly faster notification of physicians regarding alarming patient test results.

Electronic medical record reminders resulted in a 30% increase in diabetic patients and 25% increase in patients with coronary artery disease receiving recommended care.

Our electronic medical records medication ordering system provides guidance to the physician and has led to 15 percent of all orders being changed to lower cost, but equally effective medications.

Remote monitoring of elderly patients with congestive heart failure not only leads to earlier detection of possible deterioration in heart function, but also results in a 25 percent improvement in productivity for our visiting nurses.

When data such as ours and others are extrapolated across the country, the Center for Information Technology Leadership, a healthcare information technology analysis group at Partners, finds that the widespread implementation of interoperable EHRs would provide a national net savings of $78B per year (5 percent of the nation’s total healthcare costs) by avoiding medical errors, reducing unnecessary care and improving administrative efficiency. Such systems are projected to eliminate 2,000,000 adverse drug events per year across the nation.

Challenges of Health Information Technology While offering significant gains, the implementation of these systems and the achievement of improvements in patient care are very complex and difficult undertakings.

Physicians and nurses must learn new ways of doing their work. Hospital and physician practice workflow must change. At times, performing a task using a computer takes longer than using paper. For providers already facing extreme demands on their time, these changes and time commitments can be overwhelming.

Healthcare providers confront a complex financial decision when they seek to invest in these applications. While they are committed to the mission of delivering the best possible patient care, these systems represent significant capital commitments. With a reimbursement system that very often does not reward them for improving quality or support them in making these investments, their precarious financial positions and limited resources prevents them from pursuing these systems. For example, an EMR can have a five-year cost of $100,000 per physician. This cost can pose an insurmountable barrier for a physician who is facing decreasing Medicare reimbursement.

Assuming that physicians and hospitals can overcome the difficult changes in clinical practice and can find the necessary funds, the majority of them have little experience with the acquisition and implementation of EHRs. They want to proceed but they don’t know how and they are rightfully concerned with making significant mistakes. This is particularly true for the small physician practice and small community hospital.

At Partners we confront these challenges every day. And every hospital, physician practice, health center and visiting nurse agency in the country confronts these challenges.

Community Health Information Exchange To these challenges, we are beginning to add a new dimension of complexity: the formation of regional and national networks to integrate EHRs across providers. There is no question that interoperable EHRs are a necessary step in our efforts to improve patient care. But there is also no question that there is very little experience with how to organize communities, develop the necessary information technologies, identify strategies for addressing complex issues such as privacy and mechanisms to ensure the ongoing financial stability of these efforts. This complexity is compounded by the bewildering array of standards that are often inconsistent, hindering our ability to efficiently connect our systems.

There is much that provider, payers, employers, and patients can do to address these challenges and further the thoughtful adoption of EHRs. Partners Healthcare is an example of an organization that is committed to improving care through the use of information technology. We spend over $50M annually to acquire, implement and support EHRs. (This investment is in stark contrast to the $150M annual budget of the Office of the National Coordinator for Health Information Technology. A budget that, while well intentioned, is clearly insufficient to move the nation towards the widespread adoption of interoperable electronic health records).

Partners is not alone. Many provider organizations are making significant investments in EHRs. Across the country, the healthcare community and its stakeholders are coming together in national and regional forums to discuss the industry’s collective efforts, learn from each other and jointly develop analyses, guides and positions.

The eHealth Initiative The eHealth Initiative is supporting these efforts through its formation of working groups of physicians, employers/purchasers and community collaboratives whose members come together to address the mutual challenges. The eHI, national meeting, Connecting Communities for Better Health (CCBH), held one month ago, was attended by representatives of over 100 communities that have begun to implement local interoperability. The Parallel Pathways Framework of eHI has been hailed as an important guide to the industry as it seeks to integrate financial incentives, quality reporting, EHR adoption and community-based interoperability.

Federal Leadership And while, the healthcare industry and those who have a stake in the industry’s efforts to improve care, must lead and are leading these efforts, the Federal government must play a critical role in supporting this work.

A very significant national hurdle is the mis-alignment of financial incentives for EHR adoption. The provider must bear 100 percent of the costs of these systems and yet studies suggest that 89 percent of the economic benefit flows to groups and organizations other than the provider. Improvements in the safety of patient care will benefit the employer, payer and patient but there is little economic benefit to the provider. Hence the provider is confronting an investment that, while improving the care that they deliver, has a high likelihood of leading to an economic loss for the practice. At Partners, we have begun to address this problem through very constructive discussions with local payers that have led to modest reimbursement to physicians who adopt an EHR by the end of 2006.

The Federal government is the country’s largest employer and payer. The Federal Government can alter its Medicare reimbursement approaches and the provider arrangements for its employees such that improvements in care and investments in necessary information technology will be financially rewarded.

The inconsistency, and at times dearth, of necessary data and data exchange standards hinders our ability to create the necessary interoperability between EHRs and our ability to report on the quality and cost of the care that we deliver. The Federal Government can use its powers of convening and persuasion to help the industry resolve these problems. And the Government can insist that the federal health sector adopts and implements standards.

A community hospital or small physician group in Massachusetts that wants to invest in information technology can turn to me and my staff for assistance. However, if you are small physician practice or a small community hospital, there may be no one who can provide this assistance. Mechanisms are needed to bring information technology support to those providers who do not have the benefit of an information technology staff. The Federal Government can leverage its resources to help establish and sustain needed support mechanisms. The current Doctors Office Quality Information Technology program (DOQ-IT) is an example.

The Federal government should consider changes in the Stark and Anti-Fraud laws to enable organizations such as Partners to extend its EHRs and its implementation expertise to physician practices and share the costs with the physician.

Partners is an active member of MA SHARE and the Massachusetts eHealth Collaborative efforts to provide Commonwealth-wide interoperability of EHRs. And at the eHealth Initiative, we see over 100 comparable efforts across the country.

These efforts need to be nurtured and they invariable need access to seed funds. While they should strive to be financially self-sustaining within a couple of years, the availability of federally sponsored grants and loans will be a critical contributor to these early efforts.

While we at Partners have been implementing EHRs for many years, there is still much that we do not know about their impact on patient care. New technologies and innovations bring new opportunities, but studies are needed to help the industry understand the potential contributions of these opportunities. We know even less about the value of regional and statewide interoperable EHRs. The Federal Government, in particularly AHRQ, has been a major supporter of research on the value and impact of information technology in medical care. These studies provide very important insight for all of our efforts and should continue.

The Federal Government has extraordinary leadership leverage. Both elected and appointed officials can use this role to convene the industry, to encourage its participants to resolve problems, to use speeches and appearances to continuously stress the need for interoperable EHRs and to respond, as needed, to industry problems by crafting appropriate legislation. This role is not a transient one; rather it will be needed for years to come. The industry does listen.

Conclusion I know that many of the recommendations described above are being analyzed and several are in the process of being put in place. And I know that I will have undoubtedly failed to appreciate the complexity and nuances of carrying out these recommendations. However, I live the reality of implementing EHRs every day and I see the reality of my colleagues across the country. From those perspectives I believe that I can see what is needed.

All of us, and those who we love, seek healthcare. I won’t recite the now well-known numbers that illustrate the litany of problems that afflict our healthcare system. I do know that I want my kids and my eventual grand kids to have a healthcare system that has made major strides in safety, appropriateness and efficiency. And I have committed my professional life to helping to create that system through the application of information technology.

Providers, payers, employers and patients must shoulder most of the burden to improve healthcare. And they are willing to do so. I am often struck, during conversations with health care leadership across the country, by the depth of their commitment and that they will continue their EHR efforts, even if the Federal response is minimal.

However, the federal government actions or inactions will have a very significant impact on the pace of change, the degree to which we avoid mis-steps and our eventual success.

Thank you for the opportunity to testify. I welcome the opportunity to respond to your questions.