<DOC>
[109th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:24713.wais]
THE LAST FRONTIER: BRINGING THE IT REVOLUTION TO HEALTHCARE
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HEARING
before the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 29, 2005
__________
Serial No. 109-90
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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http://www.house.gov/reform
______
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COMMITTEE ON GOVERNMENT REFORM
TOM DAVIS, Virginia, Chairman
CHRISTOPHER SHAYS, Connecticut HENRY A. WAXMAN, California
DAN BURTON, Indiana TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida PAUL E. KANJORSKI, Pennsylvania
GIL GUTKNECHT, Minnesota CAROLYN B. MALONEY, New York
MARK E. SOUDER, Indiana ELIJAH E. CUMMINGS, Maryland
STEVEN C. LaTOURETTE, Ohio DENNIS J. KUCINICH, Ohio
TODD RUSSELL PLATTS, Pennsylvania DANNY K. DAVIS, Illinois
CHRIS CANNON, Utah WM. LACY CLAY, Missouri
JOHN J. DUNCAN, Jr., Tennessee DIANE E. WATSON, California
CANDICE S. MILLER, Michigan STEPHEN F. LYNCH, Massachusetts
MICHAEL R. TURNER, Ohio CHRIS VAN HOLLEN, Maryland
DARRELL E. ISSA, California LINDA T. SANCHEZ, California
GINNY BROWN-WAITE, Florida C.A. DUTCH RUPPERSBERGER, Maryland
JON C. PORTER, Nevada BRIAN HIGGINS, New York
KENNY MARCHANT, Texas ELEANOR HOLMES NORTON, District of
LYNN A. WESTMORELAND, Georgia Columbia
PATRICK T. McHENRY, North Carolina ------
CHARLES W. DENT, Pennsylvania BERNARD SANDERS, Vermont
VIRGINIA FOXX, North Carolina (Independent)
JEAN SCHMIDT, Ohio
Melissa Wojciak, Staff Director
David Marin, Deputy Staff Director/Communications Director
Rob Borden, Parliamentarian
Teresa Austin, Chief Clerk
Phil Barnett, Minority Chief of Staff/Chief Counsel
C O N T E N T S
----------
Page
Hearing held on September 29, 2005............................... 1
Statement of:
Brailer, David J., M.D., PH.D., National Coordinator for
Health Information Technology, U.S. Department of Health
and Human Services; and Robert M. Kolodner, M.D., Chief
Health Informatics Officer, Veterans Health Administration. 22
Brailer, David J......................................... 22
Kolodner, Robert M....................................... 38
Powner, David, Director, Information Technology Management
Issues, Government Accountability Office; Carol Diamond,
M.D., managing director, Markle Foundation; Janet M.
Marchibroda, chief executive officer, Ehealth Initiative
and Foundation; Diane M. Carr, associate executive
director, healthcare information systems, Queens Health
Network; and Larry Blue, vice president and general
manager, Symbol Technologies............................... 64
Blue, Larry.............................................. 114
Carr, Diane M............................................ 106
Diamond, Carol........................................... 80
Marchibroda, Janet M..................................... 93
Powner, David............................................ 64
Letters, statements, etc., submitted for the record by:
Blue, Larry, vice president and general manager, Symbol
Technologies, prepared statement of........................ 117
Brailer, David J., M.D., PH.D., National Coordinator for
Health Information Technology, U.S. Department of Health
and Human Services, prepared statement of.................. 25
Carr, Diane M., associate executive director, healthcare
information systems, Queens Health Network................. 108
Clay, Hon. Wm. Lacy, a Representative in Congress from the
State of Missouri, prepared statement of................... 19
Davis, Chairman Tom, a Representative in Congress from the
State of Virginia, prepared statement of................... 4
Diamond, Carol, M.D., managing director, Markle Foundation,
prepared statement of...................................... 82
Kolodner, Robert M., M.D., Chief Health Informatics Officer,
Veterans Health Administration, prepared statement of...... 40
Kucinich, Hon. Dennis J., a Representative in Congress from
the State of Ohio, prepared statement of................... 123
Marchibroda, Janet M., chief executive officer, Ehealth
Initiative and Foundation, prepared statement of........... 96
McHugh, Hon. John M., a Representative in Congress from the
State of New York, prepared statement of................... 125
Porter, Hon. Jon C., a Representative in Congress from the
State of Nevada, prepared statement of..................... 15
Powner, David, Director, Information Technology Management
Issues, Government Accountability Office, prepared
statement of............................................... 66
Waxman, Hon. Henry A., a Representative in Congress from the
State of California, prepared statement of................. 8
THE LAST FRONTIER: BRINGING THE IT REVOLUTION TO HEALTHCARE
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THURSDAY, SEPTEMBER 29, 2005
House of Representatives,
Committee on Government Reform,
Washington, DC.
The committee met, pursuant to notice, at 10:08 a.m., in
room 2154, Rayburn House Office Building, Hon. Tom Davis
(chairman of the committee) presiding.
Present: Representatives Tom Davis, Mica, Gutknecht,
Porter, Schmidt, Waxman, Maloney, Cummings, Kucinich, Davis of
Illinois, Clay, Watson, Ruppersberger, and Norton.
Staff present: Melissa Wojciak, staff director; Chas
Phillips, policy counsel; Rob White, press secretary; Drew
Crockett, deputy director of communications; Victoria Proctor,
senior professional staff member; Susie Schulte, professional
staff member; Teresa Austin, chief clerk; Sarah D'Orsie, deputy
clerk; Phil Barnett, minority staff director/chief counsel;
Kristin Amerling, minority general counsel; Sarah Despres,
minority counsel; Earley Green, minority chief clerk; Jean
Gosa; minority assistant clerk; and Cecelia Morton, minority
office manager.
Chairman Tom Davis. The meeting will come to order.
Millions of Americans are nearing retirement and will
become greater consumers of healthcare over the coming years.
Innovations are helping people live longer and healthier lives.
In recent years, information technology has brought great
advances in quality, efficiency, and cost savings to almost all
sectors of our economy. It has been the driver of the American
economy.
The Government Reform Committee has worked to ensure that
the Federal Government has access to the latest technology at
the lowest possible cost to bring the innovations of the
private sector to the public sector. We have witnessed the
improvements in Government services that come from harnessing
the power of information technology. Until now, however, the
healthcare industry has failed to embrace technology.
Technology that could dramatically improve the quality of
healthcare and reduce cost.
We live in a world of IT systems that handle millions of
transactions daily in real time. We interface with them
quickly, and they process our requests efficiently and
accurately. We do this when we transfer money, buy gas, or shop
online. It is routine.
But the routine in healthcare is different. It is primarily
a paper-based system of disconnected records and files in
multiple locations. Doctors continue to write billions of
handwritten prescriptions every year, a significant portion of
which are illegible, or involve incorrect or incompatible
drugs.
According to one survey, only 15 percent of physicians are
using electronic prescribing systems, and only 3 percent of
prescriptions are processed electronically. Computerized order
entry systems coupled with electronic health records offer
enormous potential.
A more troubling routine is a healthcare system in which
the Institute of Medicine reports that around 50,000 to 100,000
Americans die every year due to medical errors. A modern IT-
based system could cut errors dramatically. One can argue that
hospitals, doctors, insurance companies, and the Government are
endangering lives by moving too slowly in adopting electronic
health records. There is a direct link, in my view, between
health IT and healthcare quality and safety.
As we have seen recently with Hurricane Katrina, physicians
are often our second responders. They should have the support
of the same sophisticated IT systems as our first responders,
enabling them to respond to a crisis quickly, to retrieve and
share the critical records of information that they need to
save lives.
I hope we can bring a sense of urgency to this issue. The
recent events surrounding Hurricane Katrina highlight the need
for accessible, accurate medical records and medical
information. I am particularly interested in VHA's experience
during this period.
I hope the system that we create will help us share
information quickly, effectively, and securely, which is
something we have been pushing the Federal Government to do in
all aspects of its operations. I believe we can enhance patient
care by providing every medical professional with instant
access to life-saving information. With the information
technology available to us today, we can no longer accept
injury or death because of preventable errors.
Efforts to convert to electronic health records have met
some resistance, however. Many stakeholders have been slow to
see the long term benefits that upfront investments in new
technology can bring. Small providers could be asked to bear
burdens that benefit others initially. Fewer than one in four
doctors currently enter information into an electronic health
record.
There will be other challenges as we move from a paper-
based system. Many hospitals and doctors' offices are still
lacking in information security, physical security, and privacy
protection practices that will be needed with electronic health
records, but we have faced these challenges before.
In this committee, we work constantly to bring the best
private sector practices and procedures to the Federal
Government to encourage information sharing, information
security, and encourage the efficient use of the latest
information technology. Each of these priorities is relevant to
the health IT debate.
The healthcare industry is a fragmented and complicated
marketplace. We need to exercise caution when we are asked to
step in with regulations and mandates. I am interested in
learning what level of governmental, including congressional,
action is warranted.
We have seen a lot of action recently on health IT
legislation, and we have a unique opportunity. Many issues on
Capitol Hill can be divisive, but there appears to be broad
bipartisan support for health technology. Of course, anytime
you propose dramatic changes that affect such a broad
community, challenges will arise. I hope we can continue to
work together to solve them and move toward the ambitious goals
we have set.
The purpose of today's hearing is to highlight the
challenges and opportunities that will come with the widespread
adoption of health information technology. The principles
driving health IT are the same principles the committee pushes
Government-wide, bringing the best information technology,
policies, and practices to the Government at the lowest
possible cost. It is a goal we will continue to support.
[The prepared statement of Chairman Tom Davis follows:]
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[GRAPHIC] [TIFF OMITTED] T4713.003
Chairman Tom Davis. Now I will recognize our distinguished
ranking member who has been very active, not just in the IT
field but the health field as well, Mr. Waxman, for his opening
statement.
Mr. Waxman. Thank you very much, Mr. Chairman.
It is entirely appropriate for this committee to be holding
an oversight hearing related to the U.S. healthcare system, a
system in need of major improvement. There are more than 45
million Americans without health insurance, and that number
keeps rising each year. Millions of Americans forego needed
treatment or declare bankruptcy because of the cost of
healthcare. Unjust disparities in access and outcomes are
common across a wide range of conditions.
Today's hearing addresses a small but important part of the
solution to the healthcare system's problems, the need for
better information technology. A network of electronic medical
records may allow treating physicians to share information
about a patient's condition quickly and efficiently, preventing
redundant treatment. Computerized warnings could stop medical
errors. Access to key patient data in an emergency can
literally be lifesaving.
While improvements in health information technology may
bring many benefits, it will also bring new challenges. Privacy
is a major issue. There must be safeguards in place to ensure
that patients' health information is secure, and that the
information will not be misused.
Then there is the question of who pays. Creating an
interoperable network of standardized electronic medical
records is going to be expensive. While many are convinced that
these costs will be more than offset by the savings these
systems may offer, others are not so sure.
Some experts have raised the concern that the projections
of cost savings are based on rosy assumptions. If the American
taxpayer is footing the bill, we need to ensure that we have a
realistic understanding of what health information technology
can actually deliver.
I look forward to learning about the promise of health
information technology today, and I thank the witnesses for
coming. And I hope the testimony we receive today will form
part of a broader examination by Congress of problems facing
our healthcare system.
Thank you, Mr. Chairman.
[The prepared statement of Hon. Henry A. Waxman follows:]
[GRAPHIC] [TIFF OMITTED] T4713.004
[GRAPHIC] [TIFF OMITTED] T4713.005
[GRAPHIC] [TIFF OMITTED] T4713.006
Chairman Tom Davis. Mr. Waxman, thank you.
Jean Schmidt was appointed to the committee on September
15, 2005. She is a lifelong resident of Clermont County. She is
the first woman ever elected to represent southern Ohio in
Congress. She served for two terms in the Ohio State House.
According to the Cincinnati Enquirer, she proved effective in
passing legislation to address her district's concern.
While serving in the State legislature, she enacted
legislation to create jobs, protect Ohio's children, and ensure
access to quality healthcare. And prior to her election to the
Ohio State House, she served 10 years as a Miami Township
Trustee.
She resides in Miami Township with her husband, Peter, and
her daughter, Emily. She holds a degree in Political Science
from the University of Cincinnati. And her other interests
include auto racing and long distance running. Jean, how many
marathons have you done?
Mrs. Schmidt. Fifty-six.
Chairman Tom Davis. Fifty-six, so she will be well-suited
to our hearings. [Laughter.]
Fifty-six marathons and still counting, that is 53 more
than the chairman. I just want to say, welcome to the
committee. We are very pleased to have you here. And if you
want to make an opening statement here or not----
Mr. Waxman. Before you recognize her as a new member, I
also want to extend my welcome to her on behalf of the
Democratic side of the aisle to join our committee. You have
run 56 marathons more than I have run. [Laughter.]
Mrs. Schmidt. Well, in 2 weeks, it will be my 57th,
hopefully. Thank you so much, Chairman Davis and fellow members
of this wonderful Government Reform Committee. It is my honor
to serve with you.
I am very excited about the fact that our first topic is
healthcare because, in the Ohio Legislature, that was one of
the chief concerns that I had, that we have quality healthcare
access to all individuals in all walks of life. As an elected
official, my top priority is to make sure that our precious tax
dollars are spent correctly and used efficiently.
My seat on this committee will allow me to work with all of
you to cut waste, streamline bureaucracy, and to ensure that we
American citizens get the most from our Government. I am very
excited to work with you in the coming months. There is a lot
of work to do, so I am going to be quiet and let us get
started. Thank you.
Chairman Tom Davis. Thank you very much. Any other Members
wish to make opening statements?
Ms. Norton.
Ms. Norton. I particularly appreciate this hearing. I am
going to be in and out because there are two other hearings at
the same time. I believe that one of the most important
questions we could answer is why the healthcare industry lags
behind other industries so substantially in IT.
It seems to be there is a very deep conundrum here. First
of all, you can call this an industry if you want to, but
essentially a bunch of people who deliver healthcare is what we
are talking about. We are talking about healthcare. We are
talking about hospitals. We are talking about HMOs. We are
talking about individual practitioners.
And to bring IT to such an important sector, scattered
among the neighborhoods, if you will, scattered in every part
of our country, would itself be a feat, especially if you want
the system to be able to talk to wherever patients go.
I see an up front problem, and that is the cost of
healthcare itself. Here we have hospitals, and HMOs, and those
who provide Medicare hardly able to keep up with the most
inflationary part of the economy.
So, in essence, if we are talking IT, especially IT beyond
what my doctor has, and she has it fine. It is in her office,
but she isn't hooked up to every hospital in the District of
Columbia. She isn't hooked up to where I might go somewhere in
the country, if that is what you are talking about.
If that is not what you are talking about, then I am not
sure why we are here. If that is what you are talking about,
there has to be some incentive for an industry that can hardly
keep up with its basic mission, which is providing healthcare
for the American people, to in fact come forward with the up
front costs that IT would involve. What is the incentive for
them to do that, to hook themselves up, or to put in systems
that would allow themselves to hook themselves up with
whomever?
The beneficiary, it seems to me, in all of this would
really be the American people; it would be individuals, far
more than providers. Until we figure out who would benefit and
who would pay the cost, then the wonderful talk about IT is
going to be just that. We are not talking about putting in
computers, I do not believe. We are not talking about being as
computer savvy as my doctor is. We are talking about having
your records, so that they would be accessible wherever you go.
We are talking about the kind of use of IT that would mean
doctors would be less often the objects of malpractice suits
because they know everything about a patient because they would
be able to find that through IT, in a way now it is even more
difficult to do.
So we kind of started with the back end of how great it
would be to hook us all up. Somebody has to tackle the hard
question, cost in an industry where cost is the primary
question and cost in a industry where 43 million Americans
don't have access to a doctor and could care less about IT.
Who would benefit? Would it really be the HMO? Would it
really be the hospital? Why should they do it if, in fact, the
benefit would be to you and me? Then it seems to me the
Government of the United States has to face that it is the
American people who would benefit, and somehow or the other the
incentives have to be there for that cost to be provided for us
to benefit.
Thank you very much, Mr. Chairman.
Chairman Tom Davis. Thank you very much. Any other Members
wish to make opening statements?
Mr. Porter.
Mr. Porter. Thank you, Mr. Chairman. I appreciate the
opportunity to speak on this important issue today.
The subject of this hearing touches every single one of us
in some shape or form. Everyone here has gone to the doctor,
some more than others, but we understand what it is like to
have to visit a doctor or visit a hospital. Quality healthcare
is of great importance to everyone. However, notwithstanding
the fact that the United States is a world leader in healthcare
science, its delivery and management of healthcare is often
outmoded and very inefficient.
Over 90 percent of the activities that go into the delivery
of healthcare are centered information and information
exchange. If this component is flawed in any way, the optimal
delivery of care will not be achieved. On July 27th the
Subcommittee on Federal Workforce and Agency Organization,
which I chair, explored this very issue.
During this hearing, we explored the potential of deploying
health information technology, its implications, and its
potential for success. At this hearing, we heard testimony from
the Federal Government, medical experts, and others who are
very interested in deploying HIT for 8 million of our Federal
employees.
Hurricane Katrina and Rita shed limelight over this issue.
With millions of Americans scattering from the Gulf Coast
Region all over the country, we soon realized that many of the
hurricane victims would require adequate healthcare from many
different doctors and many different hospitals. Many medical
records were not immediately available for patients,
potentially putting some patients at even greater risk. We must
make sure that situations like this are avoided in the future.
By deploying HIT, it would be a step in the right direction.
One insurer, however, stands out as a stark example of HIT
excellence. Blue Cross Blue Shield of Texas extracted data on
its members who lived in the areas that were evacuated before
Rita hit. To help physicians care for Hurricane Rita evacuees,
Blue Cross of Texas is making its members' clinical summaries
electronically available to physicians.
The summaries contain historical and current data such as
lab results, pharmacy information, basic medical history. Some
of those members won't return home for several weeks, maybe
even months or years, because of the hurricane. Blue Cross took
its payer-based data for 830,000 members, and converted it into
electronic health records available to any treating provider
for hurricane-affected States, and did it for 4 days.
The benefits of computerizing health records are simply
substantial. Health information technology will improve the
quality of care, reduce the redundancy of testing and
paperwork, and virtually eliminate prescription errors, prevent
adverse effects from conflicting courses of treatment, and
significantly reduce medical errors, and reduce administrative
costs.
The President, in announcing his 10 year goal, admonished
the Federal Government has to take the lead. The FEHB Program
is no exception and should leverage as buying power about 8\1/
2\ million participants to support President Bush's goal and
lead by example.
That is why in the next 2 weeks, I will be introducing
legislation called the Federal Family Health Information
Technology Act. This bill will provide every Federal employee
and participant of the Federal Employees Health Benefits
Program with an electronic healthcare record and will
effectively serve as the largest HIT demonstration project in
the country.
No one can claim that moving information technology into
the healthcare industry is going to be easy; it is going to be
difficult. However, as the Blue Cross Blue Shield of Texas case
demonstrates with payer-based data, there is no reason not to
get started with the data that currently is available to the
Federal Government. The HIT bill I will be introducing
recognizes that there are three components of electronic health
record, and each component will be phased in accordingly.
The first component is the payer-based record which will
use claims data and other information readily available to
carriers. The other components, a personal health record and
provider-based record will be phased in accordingly. The bill
also requires carriers in the program to provide each program
participant with a wallet-size electronic health record
identification card within 5 years of passage of this act.
As chairman of the subcommittee, I am committed to
supporting the President's goal and this committee, full
committee's goal. Mr. Chairman, I appreciate this opportunity.
I look forward as the hearing unfolds. But realize that we are
so far behind in our technology, that many American lives are
at stake. I look forward to moving forward with my bill, which
we will be introducing, and others that have come before us.
[The prepared statement of Hon. Jon C. Porter follows:]
[GRAPHIC] [TIFF OMITTED] T4713.007
[GRAPHIC] [TIFF OMITTED] T4713.008
Chairman Tom Davis. Thank you.
Ms. Watson.
Ms. Watson. I want to thank you, Mr. Chairman, for having
this hearing this morning.
In reading over the analysis of this meeting, it says
health IT may be especially beneficial for inner city and rural
populations and other medically under-served areas. We all
witnessed a month ago how the under-served were those who were
very, very ill or became very, very ill.
What I find our problem is, it is two-fold. No. 1, we don't
have a national health insurance program, and we need to focus
on that. And No. 2, we don't have the outreach. We all assume
that communities are on the Internet. And so, as we go through
these discussions around legislation, I would hope that our
panels would address how we outreach in communities that are
under-served. That is our biggest problem.
I represent a city in California called Los Angeles, and it
is spread out. We don't access; we don't have IT; and we don't
have outreach. People suffer from lack of information, and they
suffer from inaccessibility. So as we discuss IT, I hope we
will broaden out that discussion, so we can be sure the under-
served is indeed served through this new technology.
Thank you, Mr. Chairman.
Chairman Tom Davis. Thank you very much. Members will have
7 days to submit statements for the record. We are going to now
recognize our first panel.
I am sorry, Mr. Clay, do you want to say something?
Mr. Clay. Thank you, Mr. Chairman.
Chairman Tom Davis. You are recognized.
Mr. Clay. Just very quickly, thank you for calling today's
hearing on ways we can improve the use of information
technology in our healthcare delivery system. I welcome our
witnesses today and hope to partner with them in the future on
transforming our healthcare system into an electronically based
model for medical efficiency.
In the coming weeks, like the other gentleman stated, I
plan to introduce a bill that will strengthen the Federal
Government's role in developing and strengthening electronic
health record standards while allowing private sector
stakeholders to remain innovative in their own EHR
implementation efforts. My legislation seeks to accomplish two
major endeavors.
First, it would codify the office of Dr. Brailer and
strengthen his role as the leading health information standard
setting organization in the Federal Government by establishing
stringent milestones and compliance requirements for all
Federal health agencies. We will reduce barriers to sharing
health information between agencies while providing the
marketplace a model for efficient and secure health information
exchange.
Second, the bill will establish a loan program modeled
after the William D. Ford Direct Loan Program for Students for
providing financing options among providers and organizations
in the process of establishing EHR systems. A major barrier to
developing a nationwide health information network is the
capital costs involved with the design and implementation of
the system, particularly among small providers lacking access
to capital markets or specialized financial instruments.
I believe the Federal Government ought to foster its
economic resources in a responsible manner to provide such
capital where necessary, and our Direct Loan Program provides
for us a model to do so.
Mr. Chairman, this concludes my remarks, and I ask that
they be included in the record.
[The prepared statement of Hon. Wm. Lacy Clay follows:]
[GRAPHIC] [TIFF OMITTED] T4713.009
[GRAPHIC] [TIFF OMITTED] T4713.010
[GRAPHIC] [TIFF OMITTED] T4713.011
Chairman Tom Davis. Without objection.
Do any other Members wish to make opening statements? Then
we will proceed to our first panel. We have Dr. David Brailer,
who is an M.D. and a Ph.D. He is the National Coordinator for
Health Information Technology at the U.S. Department of Health
and Human Services.
And Mr. Robert Kolodner, M.D., who is the Chief Health
Informatics Officer at the Veterans Health Administration.
First, let me thank you both for your service. It is our policy
that we swear you in before you testify, so if you would rise
and please raise your right hands.
[Witnesses sworn.]
Chairman Tom Davis. Thank you. We have a light in front of
you that will turn green when you start; it will turn orange or
yellow after 4 minutes, red after 5. Your entire statement is
part of the record, and our questions are based on the entire
statement.
So if we can keep within time, it helps. I won't gavel if
you feel you need an extra minute or so because we want to make
sure you get your points across. This is important testimony.
Dr. Brailer, we will start with you and then go to Dr.
Kolodner. Thank you very much for being with us.
STATEMENTS OF DAVID J. BRAILER, M.D., PH.D., NATIONAL
COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY, U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES; AND ROBERT M. KOLODNER, M.D.,
CHIEF HEALTH INFORMATICS OFFICER, VETERANS HEALTH
ADMINISTRATION
STATEMENT OF DAVID J. BRAILER
Dr. Brailer. Thank you, Mr. Chairman and members of the
committee. I appreciate the opportunity to speak with you today
and to continue our discussions about health information
technology.
We are far along in our efforts to begin understanding what
the Nation's work will be like to bring health information
tools to our doctors, hospitals, and consumers. There are three
foundations that have been strongly set. The first and most
important is a clinical foundation that essentially says that
the use of health information tools appropriately set up and
appropriately trained for clinicians save lives.
The second is a technical foundation that asks: Do we have
the components, and the pieces, and the know-how to do this?
And we believe that we have, if not all of it, most of it
because of the opportunities already underway in many
healthcare organizations as well as other industries. The
question of an economic foundation which is, how does this get
paid for and how does it generate economic value, is something
that has been explored at length and will continue to be as
well.
We view there being two fundamental challenges around
health information technology, and they work together. The
first is how to get these important tools into the hands of
doctors, and not just a few but all, into the hands of other
clinicians, into the hands of professionals, and consumers,
institutions, clinics, and other settings. This adoption
challenge has many pieces that include financing, culture,
training, legal issues.
And second is the question of portability of information,
or its interoperability which involves a separate set of issues
about how organizations and healthcare relate to each other and
ultimately how they can come together to deliver seamless care
for each patient.
We are now ready to begin full scale implementation of the
administration's agenda, and I would like to summarize some of
the key steps that are underway in the next few weeks. The
first is the American Health Information Community which is a
group comprised of 17 members, 8 of which are from the Federal
Government, 8 from the private sector, and 1 from a State
government.
This American Health Information Community will be the main
steering group for the health information technology agenda in
the administration. It will prioritize breakthroughs, a
breakthrough being some specific way that health information
technology can be useful to the American public. It will
balance the short term goals against long term issues as we
buildup an infrastructure and a capacity in the United States
to bring this across to all forms of healthcare and to all the
different constituents. It will ensure that various voices are
heard including those of key Federal agencies like Medicare and
the Office of Personnel Management in terms of how they can
participate and bring their Federal tools to this agenda.
Second, from that we will be setting up work groups to
oversee these breakthroughs. If, for example, a breakthrough is
a personal health record, or tools for chronic care disease
management, or e-prescribing, or bioterrorism surveillance just
to name a few, each of these will have a work group constituted
of Federal, State, and private leaders to ensure that we can
move these agendas forward, and address barriers, and work
against a very specific timetable.
The American Health Information Community has its first
meeting on Friday, October 7th. And we expect by the end of the
year to have the breakthroughs chartered, and charged, and
working against a timetable. At the same time next week, we
will be announcing the Federal Government's partner for
standards harmonization.
We do have a significant number of different, somewhat
overlapping, and ambiguous standards in the United States, and
the standard harmonization partner will help us align those
into one single fabric, one set of tools that can ensure that
information can be exchanged and shared seamlessly.
We will also be identifying our conformance certification
partner, which is another way of saying the entity that will
help us determine what are the characteristics of an electronic
health record that is used by doctors and hospitals. We will be
establishing a consortium of State leaders together to identify
security and privacy advances that are needed to protect
information the coming Information Age and address the question
of portability in the context of that security.
And finally, later in October, we will be identifying the
groups of entities that will develop models, or architectures,
or plans for what the Nation's capacity to share information
looks like. There are many technical components of these, and
we are asking for six different groups to work, so we can
extract from that and combine the very best ideas of any of
those groups.
My office has had the privilege of working with the private
sector recently in the health information response to
Hurricanes Katrina and Rita. I am happy to tell you that this
was a remarkable experience by which many groups came together
and operated well within the bounds of law to produce for up to
80 percent of the evacuees a prescription data base in a
secure, non-centralized data tool that was available to
physicians and shelters within 7 days. This remarkable
experience will redefine what urgency is in health information
and what it means to really break through and to address real
problems.
These actions that are underway will be supplemented by
other policies and other changes over the course of the next
few months that are needed to continue to drive both
portability and adoption. We have many things to do, but at
this point we are underway, and we expect to see significant
progress over the course of the next several months.
I welcome your interest in this topic, and I certainly look
forward to further discussion about it. Thank you.
[The prepared statement of Dr. Brailer follows:]
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Chairman Tom Davis. Thank you very much.
Dr. Kolodner.
STATEMENT OF ROBERT KOLODNER
Dr. Kolodner. Good morning, Mr. Chairman and members of the
committee. I am Dr. Robert Kolodner, the Chief Health
Informatics Officer in the Department of Veterans Affairs.
Thank you for inviting me here today to discuss our work in the
field of health information technology.
Seventeen months ago President Bush outlined an ambitious
plan to ensure that most Americans have electronic health
records within 10 years. The President made his announcement
during a visit to the Baltimore VA Medical Center where
patients have benefited from electronic health records for
years.
Four months ago, HHS Secretary Leavitt issued a report
which concluded that the widespread adoption of IT should be a
top priority for the American healthcare system and the U.S.
economy. Collaboration between private sector organizations,
and public sector health entities such as VA, and activities
like Connecting for Health, and the eHealth Initiative were
cited as a key factor in the advancement of health IT.
One month ago Hurricane Katrina struck, and in minutes the
IT innovations we have been pursuing for years suddenly went
from esoteric to essential. My written testimony describes VA's
health IT activities in greater detail, but I want to highlight
in my oral testimony the benefits of these activities during
this recent crisis.
VA's Electronic Health Record, known as VistA, is
recognized as one of the most comprehensive and sophisticated
electronic health records in use today. As a doctor and as a
patient, I am passionate about the use of this technology and
the very real effect it can have on patients' lives. It can
mean the difference between life and death.
How many of the Katrina evacuees with chronic medical
conditions would have been spared additional suffering if their
treatments and medications had continued without disruption
because their new physicians and access to their previous
medical records? What would have been the value to the millions
of Katrina evacuees of we had a National Health Information
Network in place to support access to their complete health
information regardless of where the evacuees sought care?
For our patients, these capabilities are not the stuff of
fantasy. Our VistA system supports secure nationwide access to
our patients' health information and gives our providers a
single place to review test results and drug prescriptions,
place new orders, and update a patient's medical history. VistA
is used routinely at all VA medical centers, outpatient
clinics, and long term care facilities across the country. That
is over 1,300 sites of care.
Of course, electronic systems of any sort are not
impervious to natural disasters. In the aftermath of Hurricane
Katrina, many of the IT systems VA relies on were interrupted,
and a great deal of work was needed to restore network
connectivity, email, BlackBerry service, and other
telecommunications. While clinicians and emergency personnel
focused on saving lives, IT staff worked around the clock to
restore access to critical patient care information.
Katrina had a significant impact on more than a dozen VA
healthcare facilities in the Gulf Coast Region. When Katrina
hit, the Gulfport VAMC was completely destroyed. New Orleans VA
Medical Center was forced to shut down their VistA system and
evacuate their patients when that city flooded. Although power
and communications were lost at the Jackson and Biloxi VA
Medical Centers, their VistA systems continued to operate
within those facilities using emergency generator power.
Although medical records were temporarily unavailable for
evacuated patients, within 1 day, we were able to provide
access to pharmacy, laboratory, and radiology results for all
of these patients using a regional data warehouse. With less
than 100 hours of effort, we were able to bring the New Orleans
VistA system back online.
And by the next week, when commercial telecommunications
were restored to Biloxi, the complete electronic health records
for all veterans were again available nationwide to help us
serve these veteran evacuees. Many patients affected by
Katrina, such as the 282 veterans from the Gulfport Armed
Forces Retirement Home who were relocated to their sister
campus less than 2 miles from the Capital had minimal
disruption in their continuity of their healthcare.
The difference between the availability of electronic
health records and paper medical records is striking. Many or
most of the paper records in the affected areas may never be
recovered. The result is that the majority of the 1 million
people displaced by Hurricane Katrina have incomplete medical
records or no medical records at all, a consequence that will
affect families and communities across the Nation.
This single natural disaster has reinforced the Nation's
need for a host of technical advances from electronic health
records and personal health records to secure communications
networks. The VA quick recovery of crucial health information
after Hurricane Katrina simply would not have been possible
without VistA. Our experience confirmed that VA's health IT
strategy, including our new initiative to provide personal
health records to veterans, has been a good one as we continue
to invest in, refine, and improve our information technology
solutions to support the future models of healthcare.
One of the most important vehicles for achieving the
President's vision for health IT is the AHIC which was
discussed by Dr. Brailer and convened by HHS. We are delighted
that VA's Under Secretary for Health, Dr. Jonathan Perlin, will
serve as one of the 17 AHIC Commissioners. I invite each of you
to visit a VA medical center to see our systems firsthand. We
look forward to sharing our systems, knowledge, and expertise
with our partners through the healthcare community.
Mr. Chairman, this completes my statement. I will be happy
to answer any questions that you or other members of the
committee have.
[The prepared statement of Mr. Kolodner follows:]
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Chairman Tom Davis. Well, thank you both.
Dr. Brailer, let me start with you. You mentioned the
adoption gap in electronic health records between large and
small hospitals, and you mentioned several areas you are
focusing on to bridge that gap. Ultimately, isn't this about
money and resources?
Dr. Brailer. Money and resources are clearly one of the
fundamental challenges, but there are also numerous other
barriers as well. I will just identify a few. First, to the
financial resources, we know that for many providers, they
invest in health information technology and can't recover those
investments. This is because either they are small or because
of the way they are paid, but this is a challenge for some
organizations.
But beyond that, there is a technical capacity and
technical know-how. Many large organizations do have
substantial resources of experts about information technology
and small organizations don't have that. Large organizations
also have the capacity to operate, if you would, strategically
to be able to understand how they can get the benefits from
these tools as they compete in the market, and many small
organizations cannot.
So the gap of adoption is multifaceted and can't be crossed
only with money. And it means raising the know-how of these
organizations, providing to them resources to help them
implement these complicated systems, and re-engineer their
workflows to change the way their business operates, and to
have the kinds of benefits that other large organizations
bring.
Chairman Tom Davis. Transforming the use of IT in
healthcare delivery is a huge task. What kind of incentives
does the Federal Government need to create to keep the private
sector involved?
Dr. Brailer. Many payers have looked at this question. And
the Federal Government is able to operate really in two ways
with respect to this healthcare financing question. First, in
CMS, and Medicare, and Medicaid, there is activity underway
through demonstration projects and forthcoming through MMA
implementation for CMS to provide incentives for health IT
adoption through pay for performance programs, essentially
allowing organizations that are paid somewhat of a differential
for performance to be able to get a bonus for health IT.
And this is consistent with how the private sector has
viewed the role of other payers providing ultimate payment for
the value that health information technology brings. Second,
through organizations like the Office of Personnel Management,
many other purchasers of care, other large employers are
looking at how to direct their health plans and other carriers
to support health information technology adoption among
providers. There are many ways, and this is consistent with how
we view the Federal Government's role of being a catalyst and a
purchasing promoter of good health IT.
Chairman Tom Davis. Dr. Kolodner, has VA's VistA project
been able to demonstrate any improvements in quality of care?
Dr. Kolodner. Yes, Mr. Chairman. The VA's VistA system is
part of a suite of activities including performance measure
that VA has used to improve its quality of care over the last
10 years, and we currently have quite a number of performance
measures that are published in the literature that show that
VA's quality of care meets or exceeds that quality of any other
healthcare system in the country. There have been reports by
the Rand Corp. that have been published to that effect, and
other measures that we have.
Chairman Tom Davis. Dr. Brailer, recent articles report
that the State and public health officials, who have a lot to
gain from the improved use of IT in healthcare, are feeling
excluded from national strategy efforts. Are you working to
better include health IT efforts? Do you think these are
justified? Are we doing things like establishing regional
health information organizations and national health
information networks? Can you talk a little about that?
Dr. Brailer. Sure. I am unaware of those reports, and I am
frankly surprised by them. I think one of the most interesting
and useful aspects of health information technology is the
grassroots nature, both at the State and community level.
We have seen more than 200 regional areas come together and
form regional health information organizations where a local
group is able to begin understanding what they can do to bring
these tools to their doctors, hospitals and consumers, to be
able to address privacy concerns and other security issues, to
support adoption financing and other things. It is a remarkable
effort, and it is something that didn't happen at the behest of
the Federal Government or at any other entity; it came together
because of this broad grassroots interest.
Also, many States are involved and have activities
underway. I have personally visited 20 States so far that have
health information technology efforts underway, and we are
working very closely with them. This one new collaborative
relationship we are about to establish around security and
privacy will be directly with States, working together to
understand how we can advance security and privacy rules.
So I think that there is a significant amount of activity
underway, and we work very closely with them, and I certainly
look forward to expanding that in the future.
Chairman Tom Davis. Thank you very much.
Mr. Clay.
Mr. Clay. Thank you, Mr. Chairman, and I thank the
witnesses for being here.
Dr. Brailer, there is no questioning the leadership you
have provided the Government in the area of electronic health
records, but I am concerned that you do not have adequate
resources or authority to bring all Federal agencies into
compliance. What barriers do you see having an impact on
getting the Federal agency community to adopt and implement
health informatic standards developed through your office? Has
there been agency resistance to particular initiatives begun by
your office?
Dr. Brailer. First, thank you, sir. I appreciate the
support for what we are doing.
It is certainly the case that before this office was
created, many different Federal agencies viewed them having a
charge to support health information technology, or standards,
or things related to this.
And as you might not be surprised to know, they worked
somewhat independently, agencies in the Veterans Affairs
Department, DOD, and HHS. I have been very well received by
these agencies, in fact more than I expected, and beyond that
we have had very good working relationships with them to
address these foundational questions on standards.
Let me give you two examples. We will announce this new
partner for standards harmonization, and that entity will be an
entity where all the Federal agencies come together, along with
the private sector, to agree on a common set of standards. And
this has been done with and through the agencies.
Second, in our certification partner, it is the same thing,
where many agencies are involved in this effort, and we will
look and take their cues from that as well. We are doing other
things internally to make sure we have alignment in our goals
and alignment in our plans, but I would never characterize our
relationships with the agencies as not cooperative and not
focused on the same goal. There are certainly more things we
can and will do, but I am very, very happy with the amount of
progress that we have made to date.
Mr. Clay. That is good to hear. Perhaps this is somewhat
forward thinking, but can you expand on the measures and
outcomes you will be utilizing to demonstrate progress and
efficiencies achieved through a nationwide health information
infrastructure? Are there sufficient tools in place to measure
the benefits of implementing an interoperable standard
structure for electronic health records? And also, have you
thought about how to protect the privacy rights of patients?
Dr. Brailer. Thank you. It is something that I am happy to
speak about. We actually very soon will be announcing a
contract with an independent third party that will perform an
annual survey that looks at the adoption of electronic health
records and the electronic transactions that share clinical
data.
And that gets to the very base level of: Are these tools
being put in place? Are they being put in place across both
urban and rural settings, across large providers and small, in
different specialties or different other settings? We want to
understand that, and we want it to be done objectively. So that
will be underway starting this year.
There are two levels above that. One, given that these
tools are adopted, the question becomes: Are they being used?
And we have been working with a variety of organizations that
already inspect or observe what clinicians do in their offices
or what hospitals do. They are onsite, like NCQA and the Joint
Commission, to understand what they can do to being looking not
at adoption but are they being used.
And then the final question, and the one where we all want
to be, is: What are the outcomes? I have been very encouraged
by the studies that are done in some of the large pay for
performance projects, where organizations that do have health
information technology do substantially better in their
performance than those that do not. So we want to look for the
final value that is realized by the American public.
And to your comment, there are negative outcomes, the
potential for privacy breaches or new abuses that come from
this data, and this is exactly what the Security and Privacy
Consortium will speak to. What do we need to put in place at a
business policy or a public policy to ensure that as we move
into the Information Age that we have policies and tools to
take us there as well? We will be watching for complaints,
privacy breaches, things that are already being reported but
asking an additional question about: Is this related to an
information tool, or is it paper?
Mr. Clay. That is reassuring to know that you are sensitive
to the privacy issues and how we protect the patients to the
utmost. One last question, the Federal Government seems to be
an appropriate vehicle to coordinate the development of a
National EHR System but have State and local governments begun
the widespread use and implementation of these systems?
Dr. Brailer. We have had, as I commented with the prior
question, very encouraging relationships and progress with
States, but it is variable. There are about 20 States that have
been quite enthusiastic, that have come forward and are working
with us, that are looking at how they can incorporate support
for health IT in, for example, their Medicaid program, or in
looking at their own State privacy laws, or at licensure
issues, or at encouraging adoption in State funded or county-
funded clinics and other settings.
And then other States are, I would call, neutral. We have
none that have really been adverse or opposed to this, but
there are some that I think see differential priorities, other
things they have to do first. So we are working more with the
willing today, but we want to create an imperative where all
the States see this as something fundamental to what the State
government does.
Mr. Clay. Thank you for your response. Thank you, Mr.
Chairman.
Chairman Tom Davis. Yes, ma'am, the gentlelady from Ohio,
any questions?
Mrs. Schmidt. No, thank you, Mr. Chairman.
Chairman Tom Davis. Mr. Gutknecht.
Mr. Gutknecht. Mr. Chairman, I am not sure I have a
question as much as a comment.
First of all, thank you for this hearing, and we really do
appreciate it. I have a keen interest in this whole subject,
and I think as we go forward, this is going to become more and
more important. I am delighted that at least there are people
inside our Government who do take it seriously.
Let me talk about this from a somewhat different
perspective. I also chair a committee of the Rural Caucus that
has been interested in telecommunications policy. Ultimately,
this issue and telecommunications policy do meet, and they are
inexorably intertwined.
One of the things that we learned, and I suspect that you
have probably already bumped into this, and that is that an
awful lot of the constituencies for the services we are talking
about here today live in small towns. Many of those small towns
do not have the same kind of broadband access that some of us
in larger communities take for granted.
We had three separate hearings. What we learned in those
hearings was that one of the things that is important, if we
are going to continue to build out broadband services to small
towns and rural parts of America, is that we have to have a
Universal Service Fund. I don't know how familiar you are with
that, but it is important to those small, rural providers. In
Minnesota, all of the telecommunications people want to serve
Bloomington, MN; not many want to serve Blooming Prairie, and
that is a big problem.
That problem becomes worse because the telecommunications
business is changing and evolving even as we speak. A year ago
I didn't know what VOIP was, but it is a fact of life, and it
is going to become more and more important. Voice Over Internet
Protocol is going to become more and more important. What we
have is more of these companies who want to use the network, so
to speak, but they don't want to help pay for the network.
I think this is for the benefit of members of the committee
as well. I understand that the Commerce Committee here in the
House is working on a telecom bill, and we hope to have it out
on the floor. And it is going to have some good things in it.
I don't want to be critical, but one of the most important
things, I think, is going to be ignored. That is: How are we
going to deal with this Universal Service Fund in a
telecommunications industry that is changing so fast? I am
afraid that all of the good work that you are doing here on
this area, well, not all, is going to be wasted, but some is
going to be wasted because we don't have that last mile and we
don't have an awful lot of our rural communities included.
If we don't come up with a reasonable solution to the
Universal Service Fund issue, who pays and who gets to draw
out, and for what services can it be used for? It strikes me
that is going to be very, very important to your deliberations
as you go forward.
Dr. Brailer. Perhaps just a comment on that, I certainly
can't comment on the Universal Service Fund, but I think it is
not coincidence that the President announced the health
information technology agenda in the same speech where he
announced the administration's broadband efforts. They are part
and parcel.
We need that infrastructure to do the things that we are
discussing, and the things that are happening here give value
to why those broadband networks need to exist. I think this is
particularly true in rural areas as you described because today
we are talking about the sharing of labs, and prescriptions,
and other things that are not very heavy in bandwidth.
But not too far out we are talking about telemedicine, and
remote video, and monitoring live feed devices that are in
people's homes or on their bodies for monitoring their
physiological status, and those are bandwidth dependent. So I
think this is moving very quickly where it will become
something where we will say, here is a value that broadband
will give us.
This is an issue that I am particularly sensitive to, being
from a very small town in West Virginia that has an 18-bed
hospital that I am proud to tell you my mother is on the board
of. We look at this quite a lot and say: How do we make sure
that we are raising the playing field for everyone?
Mr. Gutknecht. You say that you can help us by putting a
little pressure both on the administration and some of our
colleagues in Congress, but ultimately we have to resolve this
issue of the Universal Service Fund because all the other
efforts we have, I think, dwarf in terms of the relative
importance to rural communities in building out that broadband
service.
Because if we don't get that done, all of these magic
things, and I have seen a lot of them, and I agree with you.
The potential of this is enormous. But you can't do that if you
don't have the wire or the cable to carry the information.
Dr. Brailer. I will make sure that message is conveyed.
Mr. Gutknecht. Thank you.
Dr. Brailer. Thank you.
Chairman Tom Davis. Ms. Watson.
Ms. Watson. From the outside looking in, what would you
suggest we do here? Now we were just discussing the fund, and
if this is going to work to service the entire Nation, and I
would hope it would do that.
What do you see as the obstacles? How could we remove them
and make it work in the small areas that most of this
technology never reaches? And how do we get to the under-
served? What would you suggest? I address that to both
panelists.
Dr. Brailer. Thank you.
Ms. Watson. And blue sky, you know. Don't worry about the
budgetary restraints; let us worry about that. What would you
suggest to make this an effective, operational system?
Dr. Brailer. Thank you. I don't get asked to do that very
often. [Laughter.]
Again, I think we need to recognize that if we look at, for
example, an urban population or a population that is under-
served, their healthcare system has numerous challenges around
delivering basic services in addition to health information
technology.
So if you look at, for example, many community clinics or
county-funded clinics, they have certainly financial challenges
of being able to support the adoption and use of tools, but
they also have a significant manpower issue in terms of just
skill base, people that understand technology, being able to
negotiate the contracts to procure the services, etc. I think
it is a combination of support financially plus the kinds of
know-how.
One of the things that, in the tool that has come out
through CMS from VA, the VistA Office EHR, the one area where
we think there is real opportunity is being able to make that
tool available into those kinds of settings because it can give
support, but it also involves not a lot of the legal issues
around negotiating those contracts and other things.
How the funding actually comes to be, I certainly couldn't
comment, except to say that I have been impressed at the
variability of Medicaid programs and the extent to which they
either take a forward leaning posture on technology use in
clinics and other settings, or they don't.
I am encouraged to see some of the ones have been quite
supportive, and I have visited a number of clinics that I think
would by far exceed what many private sector providers have in
terms of their technical capacity to really care for patients
in a seamless way. So I think it can be done, but I would not
say it is money alone. I am really worried about the Nation's
overall manpower supply of experts in this field, particularly
how it is distributed into those settings.
Ms. Watson. What resonated with me in the beginning of your
statement was the fact of training. I ran a program back in the
1960's at UCLA and Allied Health. We said, 10 years from now,
that was 1960, there will be 10,000 new jobs that we don't know
about today. Well, there must be 300,000 new jobs that
correspond to the developing technology.
So maybe there should be a training component. Whatever we
do, we ought to have a training component so we will have
personnel out in the field that can indeed utilize this new
technology to its fullest extent. I appreciate your input, and
I ask my staff to take notes because maybe we will come up with
a piece of legislation in addition to what is already on the
table.
Dr. Kolodner. I think also the idea is the technology has
to adapt to the individuals. All of us can use telephones right
now; they are simple to use. Trying to program your VCR still
is a challenge for many people.
I think that as those of us who are in the technology field
look forward, particularly as we get into the personal health
records which I think will, in fact, revolutionize the
relationship between the providers and the patients--raising it
up so that the provider, in fact, becomes the expert counsel to
the patient instead of the caretaker for the patient and
empowers people to take control of their health as they move
forward. Things like the personal health record, or even the
electronic health record for the providers, have to be simple
to use; they have to be understandable; they have to be able to
be tailored to the particular style, or reading level, or
others of the person who is using it.
Ms. Watson. Thank you.
Chairman Tom Davis. I recognize Mr. Porter.
Mr. Porter. Thank you, Mr. Chairman.
Dr. Brailer, are there still a lot of disincentives out
there for the industry to get into technology, the providers?
Are there some barriers that we should be breaking? It seems to
me we do a lot of Government incentives, and there are grants,
low loan rates, which are all good things. Assuming that there
are some barriers, which I think there are, is there something
we can do market-driven, to help jump start this?
Dr. Kolodner. Let me start just by saying that one of the
things, if you look at VA, Kaiser Permanente, DOD--where there
have been advances for large systems in the use of the
information technologies--they are systems where the systems
are both the provider and the payer because it is really on the
payer side that a lot of the benefits occur. Actually, it is at
the level of beneficiary.
But in terms of the people who are making the decisions,
the payer gets the benefit of not having duplicate tests and
being able to operate more efficiently. Over the last 10 years,
VA has doubled the number of patients that we have seen with
only about a 15 percent increase in our budget at a time when
healthcare has been double digit. Not all of it, but a good
part of it, had to do with putting in the electronic health
records, helping us to be more efficient.
Dr. Brailer. It is a great question. It is one that we
obviously spend a lot of time with. It is no surprise that
large physician groups or prepaid group practices are among the
Nation's leaders in the use of advanced health information
technology because they live in a world that has both clinical
care and bottom line risk in the same organization, and they
have few, if any, barriers to collaboration between doctors and
institutions.
Mr. Porter. Plus, they have the resources in many respects.
Dr. Brailer. Sure, they do. As we think about how do we
extend that across the industry, I think the question is not
how do we provide incentives per se, but how do we take away
the perverse or the contrary incentives to not invest because
it is against the financial interest of many providers to
actually put in tools that improve quality or improve
efficiency. That is because we pay for volume, and efficiency
and quality by definition reduce volume.
So that is a real challenge I think that is across the
industry. Many physicians and hospitals want to do the right
thing if we could at least make the incentives neutral with
respect to that.
Second, there are barriers to doctors and hospitals
cooperating around the care of their patients in a way that can
improve quality. Health information technology is just one, one
very large but just one, of those areas.
Then third, as we move toward this concept of
interoperability, most of the technical infrastructure is built
with the concept of somewhat proprietary data, that the data is
very difficult to move and that many of our technical companies
make a lot of money in their revenue cycle from implementation
of somewhat standardized tools. In a world that is highly
interoperable, or plug and play, means a fundamentally
different kind of value stream for them as well. So there are
barriers up and down the supply chain of health IT, if you
would, that need to be addressed.
Mr. Porter. Mr. Chairman, if I may continue. It was
mentioned earlier there are those pockets in the country that
are under-served by healthcare and technology. One of my goals
in the legislation I am proposing is if you take a group the
size of the Federal Government, 9\1/2\ million people, and by
having the proper encouragements in place to have the
providers, doctors, and the patients involved in the system, it
hopefully will flow into the rest of the free market system
because the systems will be in place.
But I know that there are small doctors that are
piecemealing systems because they can't afford to get into it,
like the clinics and the combinations. There are small doctors
across the country that would like to, but then there are those
that don't want to change. There is the culture of this is the
way we have always done things.
It seems to me if we can help provide an incentive, a
market-driven incentive to make sure that those doctors that
use the latest, and providers throughout the system use the
technology, there may be some incentive to reduce their medical
liability insurance, and have medical liability carriers
engaged in finding a way to provide assistance because it
reduces, of course, the loss of life and injury, but on the
dollar side reducing some costs. So part of the legislation I
am working on will hopefully provide some incentives to reduce
medical liability insurance costs because the losses are fewer,
which in turn could be returned.
I understand there are lots of barriers. We have to come
out of the Dark Ages as soon as possible. I appreciate what you
are doing. You guys, you are on the cutting edge. I am not sure
about the title of our hearing, the Last Frontier. I think this
is the frontier; we are there. I appreciate what you are
providing for us today, and I look forward to working with you.
Chairman Tom Davis. Thank you.
Ms. Norton.
Ms. Norton. Thank you, Mr. Chairman.
I appreciate that you have talked about some of the
barriers. They are pretty big barriers. I spoke about one
barrier. Mr. Porter, who has just spoken, had a hearing in
another of our subcommittees on which I serve on this issue. It
is absolutely fascinating because of how hard it is to get a
handle on it. It would be hard enough if, given the
decentralized nature of the sector, if costs were the only
barriers, but when you really get into interoperability and you
get into other technical matters, you get into personal
matters, and cultural matters, and professional ethics, and
age, they are quite awesome.
I am interested in the VA. When we had our hearing in
subcommittee, it was a subcommittee that deals with the Federal
Government and Federal workers. I noticed, Dr. Kolodner, that
on page 6 of your testimony, you say, you use an example which
is the best way to make people understand a subject like that.
You said, suppose a veteran comes in for a check-up and
tells a physician he is allergic to drugs, etc. So the first
thing I want to know is once a veteran is in the system in one
part of the country, does that mean his records are accessible
in every veterans' hospital throughout the country?
Dr. Kolodner. Yes, it does, whether that is progress notes,
whether that is lab results, radiology reports. Actually,
starting this month, we started rolling out a new capability so
that all of the images that exist at one hospital are available
in any another.
Ms. Norton. I just think this is very important. This isn't
going to happen unless the Federal Government shows it can
happen. And here we have closed system here. We are the
Government. We can make things happen in our organization, the
largest organization in the country in a way that even the
largest HMOs would have more difficulty because we can
appropriate money.
We can do it through pilot projects, or we can look at what
the Veterans Administration is already doing, and remove some
of these barriers simply by showing, in fact, what the benefits
are. The benefits are to all involved, but that is certainly
not immediately apparent to all involved in today's healthcare
world.
You say, for example, on page 9 of your testimony that
about 40 percent of veterans that come to one of your
facilities each year receives care some place out from non-VA
physicians, and you are now beginning to tackle that notion. I
see you as a possible pilot here. When you go from your own
system, which you appear now to have a hold of, you now have to
deal with the fact, the kind of situation rather, that
healthcare outside of the Government will face.
I would like you to discuss how you expect to be able to do
for that 40 percent what you can do for those within your
system and what you can do about keeping track within your
system. It might not matter if, in fact, you get somebody
seriously ill, for example, who normally does not come to your
system--and perhaps you both have talked about Katrina and
Rita--if, in fact, healthcare is normally received outside of
your system. Will you speak to that, please?
Dr. Kolodner. Yes. The figure that you cited, the estimated
40 percent of veterans we treat each year getting care outside
of VA, is one of the very reasons why VA has been very active
both in the area of standards development that was mentioned
earlier as well as the close working relationship we have with
Dr. Brailer's office and our active participation in public/
private initiatives such as those you will be hearing about on
one of the subsequent panels with the eHealth Initiative and
the Connecting for Health.
That allows us to work with others because we are not going
to be able to solve this alone. We need electronic health
records on the outside. We need those National health
information networks that we can connect into. We can certainly
contribute our experience, the things that we have learned
along the way as we have brought up the systems and connected
our hospitals, and as we have worked with the Department of
Defense to connect these two large departments, and where we
are moving information back and forth bi-directionally between
the two departments in order to help our veterans, some of who
are getting care at the Department and Defense.
But it is really in the public/private initiatives and with
Dr. Brailer's office, where they have the charge for these
broader community initiatives that we are really able to----
Ms. Norton. So you are really not able. If this veteran who
is not in your system comes in, and now you have a lot of
information that you get from him, are you able to connect with
his HMO, let us say, if in fact that HMO could speak to you
through your system? Would some of the barriers that we have
been discussing be such that you could feel that you could use
IT to retrieve data about him rather than relying on the old-
fashioned methods?
Dr. Kolodner. We can't do that today. That is the goal, and
that is to work with the regional health information
organizations and with these other organizations in order to
establish the standards, the protocols, and the rules of the
road for accomplishing exactly what you are talking about.
Ms. Norton. Dr. Brailer, I must say, I see what your doing.
It is very complicated. I really think in the busy world of
HMOs and physicians, it is so complicated that unless somebody
can set up a pilot that somebody sees works, this is just not
going to work. The best, it seems to me, possibility might be
within the VA and some kind of pilot involving the VA and
patients who are not regularly in VA or who are sometimes in VA
and sometimes not in VA, because setting people down to even
want to do this is a task unto itself.
The cost task is such that even in your testimony, Dr.
Brailer, you are cautious, and I think that is being very
responsible about whether anybody should be promised cost
savings. Ultimately, as with almost everything in our country,
if we see a system that works in this way, that has solved the
considerable problems in your testimony, it seems to me that we
will have a better chance of connecting our healthcare system
than I see us having now.
I just think this is a show-me country and if we can't show
the country a system that works, then I think we are not going
to be able, in the context of costly healthcare today, to move
ahead, particularly when it is normally provided by private
parties.
Thank you, Mr. Chairman.
Mr. Gutknecht [presiding]. Mr. Ruppersberger.
Mr. Ruppersberger. Sure. Excuse me if I duplicate some of
these questions, but I had to come late.
First, there are many issues involving a national health
information system, but one of my major concerns is making sure
that the various healthcare systems nationwide can talk to each
other. It serves no one any good if we have a bunch of networks
and data bases that can't talk to each other and that are not
centralized. Now where are we as it relates to where you are
and where we need to move forward as far as the systems talking
to each other?
Dr. Brailer. We have what I would consider to be numerous
pieces that are now coming together. We have, for example, in
the regional and local areas these 200 or more projects that
are trying to build the capacity to do what you described, to
share information, to talk together, to make it seamless. And
those organizations go from those that who do have actually
very good demonstration sites of what has happened to those
that are still moving forward, including one here in D.C.
At the same time at the Federal level, we are trying to
make sure that there are a single set of standards and a
capacity, this national health information network architecture
that can tie these together. So we are trying to converge all
of those pieces together to make sure that the easy thing for a
doctor or a hospital to do is to be online and sharing their
information with other doctors and hospitals as the patient
permits.
Mr. Ruppersberger. Are there any lessons learned that you
can pass onto the private sector in your efforts to create an
electronic health record system? Anyone?
Dr. Kolodner. There are many lessons that would be
something. Actually we have a report the GAO did where we
talked about lessons learned between VA and DOD in terms of the
information exchange. The ability to meet the needs of the
provider, and make sure that the systems are fitting the
workflow, and are not designed from the outside by non-
clinicians but actually are shaped by the needs of clinicians,
so that it fits into their clinical practice is an important
way of succeeding with the electronic health record part.
But the focus really needs to remain on the fact that IT is
an enabler. It is not an end itself; it is the means for
delivering better quality of care and safer care.
Mr. Ruppersberger. Let me talk about the issue of barriers.
Sometimes we, in Congress, try to fix a problem and when we fix
it, it sometimes makes the problem worse. Even though we need
to deal with the issue of confidentiality, I think HIPAA is an
example.
It seems to me that people in the medical field, from
either a hospital perspective or doctors, are involved in so
much paperwork now, that even HIPAA has gotten to the point of
maybe giving people excuses, some in the medical field: When
you have a parent that has dementia, well, I can't talk to you
because of HIPAA. It has also been said that HIPAA is great for
the paper business because there is a lot of paper generated.
How would you look at the issue of HIPAA as it relates to
what we are talking about here today, and how would you solve
maybe some of the tremendous administrative wastes of time and
personnel that are focusing more on HIPAA than actually
treating patients?
Dr. Brailer. I think HIPAA is a good example of where the
information age can be advantageous in many ways. For example,
providers do have concerns about being burdened with the costs
of accounting and disclosure. Information-based exchange is
much less manually intensive. It is cheaper for them to keep
track of who they gave data to and how to release that data.
So I think information tools are actually a positive thing
in a HIPAA world. Second, with respect to consumers that want
to get their data, electronic data is easier for them to get,
and get access to, and give to third parties. The information
age, I think, will let consumers be much more engaged in not
just getting their information but controlling who has access
to it.
I think the one challenge, not really in HIPAA but across
the States that have often superceded HIPAA with their specific
State requirements, is the concept of flexibility. Flexibility
here means that the way a hospital or a doctor implements their
security and privacy regime varies from very small
organizations to very large ones.
That flexibility is often at odds with data portability. It
is not a security or privacy issue, per se; it is an issue
about whether or not those create barriers to information
exchange. That is exactly what this project is going to do,
where we bring together all the State leaders and regional
leaders to understand what they can do to have both flexibility
and data portability at the same time. So I think it is a
positive step, and we will be looking at that from the
perspective of what are the protections or guidances needed to
make sure that we can protect data yet have it be portable as
the patient chooses.
Mr. Ruppersberger. OK, thank you.
Chairman Tom Davis [presiding]. Any other questions? If
not, that is all I have for this panel. We appreciate it very
much.
Just let me ask, in the interest of time, we are going to
combine panels two and three. We appreciate this very much. We
will take a 2-minute recess. And I want to thank Mr. Powner for
his flexibility and assistance in letting us go to two panels,
so we can try to get to a prospective noon vote.
On our second panel, we have Mr. David Powner, who is the
Director of Information Technology Management Issues at the
GAO; Carol Diamond, M.D., the managing director of the Markle
Foundation; Janet Marchibroda, who is the CEO of eHealth
Initiative and Foundation; Diane Carr, who is the associate
executive director of Healthcare Information Systems, Queens
Health Network; and Mr. Larry Blue, the vice president and
general manager of Symbol Technologies.
[Recess.]
Chairman Tom Davis. As you know it is our policy that we
swear everyone in. If you will rise with me and raise your
right hands.
[Witnesses sworn.]
Chairman Tom Davis. Thank you very much. We will start with
you. I think everyone understands how we try to operate on
time. With GAO, if you need a couple of extra minutes to do it,
your whole report is in the record, and we have worked up
questions based on the entire testimony, but take what you need
to highlight what you need.
Thank you all for being with us.
STATEMENTS OF DAVID POWNER, DIRECTOR, INFORMATION TECHNOLOGY
MANAGEMENT ISSUES, GOVERNMENT ACCOUNTABILITY OFFICE; CAROL
DIAMOND, M.D., MANAGING DIRECTOR, MARKLE FOUNDATION; JANET M.
MARCHIBRODA, CHIEF EXECUTIVE OFFICER, EHEALTH INITIATIVE AND
FOUNDATION; DIANE M. CARR, ASSOCIATE EXECUTIVE DIRECTOR,
HEALTHCARE INFORMATION SYSTEMS, QUEENS HEALTH NETWORK; AND
LARRY BLUE, VICE PRESIDENT AND GENERAL MANAGER, SYMBOL
TECHNOLOGIES
STATEMENT OF DAVID POWNER
Mr. Powner. Chairman Davis, Ranking Member Waxman, and
members of the committee. We appreciate the opportunity to
testify on healthcare information technology. As we have
highlighted in several recent reports completed at your
request, Mr. Chairman, significant opportunities exist to use
IT to improve the delivery of care, reduce administrative
costs, and to improve our Nation's ability to respond to public
health emergencies.
This morning I will briefly describe the importance of
defining and implementing standards to achieve the President's
goal of nationwide implementation of interoperable healthcare
systems. I will also summarize key administration efforts to
further define standards and conclude by highlighting key items
for consideration.
IT standards enable the interoperability of data and
systems and defining such standards can help speed the adoption
of IT for the healthcare industry. For example, standards are
essential to provide greater consistency of patient medical
records. Standards-driven electronic health records have the
potential to give caregivers with complete and consistent
medical histories necessary for optimal care. Standards are
equally important as systems are pursued to detect and respond
to public health emergencies including acts of bioterrorism.
This past summer, Mr. Chairman, we issued a report to you
that highlighted the importance of developing and adopting
consistent standards to enable interoperability of key
surveillance systems like CDC's BioSense and Homeland
Security's BioWatch. Despite this critical need, today's
standards are uncoordinated and have resulted in conflicting
and incomplete standards. We recommended several years ago that
the Secretary of HHS reach consensus across the healthcare
industry on the definition and use of standards and to create
mechanisms to monitor the implementation of standards.
HHS has taken several actions that should help to define
standards for the healthcare industry. First, the coordinator
has assumed responsibility for the Federal Health Architecture
which is expected to include standards for interoperability and
communication. This architecture effort now also includes the
Consolidated Health Informatics Initiative, one of the original
OMB eGov initiatives to facilitate the adoption of Federal
healthcare standards.
Second, HHS agencies continue to identify standards
including those for clinical messaging, drugs, and biological
products. Third, HHS plans to leverage private sector expertise
by awarding a contract to develop and evaluate a process to
further define industry-wide standards. In addition, HHS also
formed a public/private committee to help transition the Nation
to electronic health records and to provide input and
recommendations on standards.
The importance of a national health information network
that integrates interoperable data bases was just recently
highlighted on a smaller scale with the coordinator facilitated
the development of a web-based portal to access prescription
information for Katrina evacuees. This online service is to
allow authorized health professionals to access medication and
dosage information from anywhere in the country and was made
possible when commercial pharmacies, health insurance programs,
and others made accessible the prescription data.
Although Federal leadership has been established, and plans
and several actions have positioned HHS to further define and
implement relevant standards, consensus on the definition and
use of standards remains a work in progress. Key items to
consider as the administration moves forward with this vital
effort are completing detailed plans for defining standards
that include private sector input, fully leveraging the Federal
Government as a purchaser and provider of healthcare, enlisting
consumer support to a point where patients demand electronic
health records, and providing incentives for the private sector
to participate and partner.
In summary, standards are essential to achieving
interoperable data and systems, and are critical in the pursuit
of electronic health records and public health systems.
Clearly, vision and leadership are now present, but detailed
plans associated with the National framework remain incomplete,
and we are still quite far from sufficiently defining standards
necessary to carry out this vision.
Once this occurs, the healthcare industry will confront the
more difficult challenge of consistently implementing a
comprehensive set of standards. Until these standards are
implemented, the healthcare industry will not be able to
effectively exchange data and, consequently, will not reap the
costs, clinical care, and public health benefits associated
with interoperability.
This concludes my statement. I would be pleased to respond
to any questions that you have.
[The prepared statement of Mr. Powner follows:]
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Chairman Tom Davis. Thank you very much.
Dr. Diamond.
STATEMENT OF CAROL DIAMOND
Dr. Diamond. Thank you, Mr. Chairman and other members of
the committee. Thank you for having me here today.
In my role at the Markle Foundation, I chair an initiative
called Connecting for Health which is a unique public/private
sector initiative consisting of over 100 organizations who
represent all the stakeholders in healthcare. Over the last few
years we have participated in shaping the National drive toward
interoperable health information by building broad consensus
about a road map of immediate actions and priorities, and most
recently by developing a working prototype of an electronic
national health information exchange based on common open
standards and policies. Our prototype, which includes the
exchange of information both within and among local
communities, is deployed in northern California, Indiana, and
Massachusetts.
As this hearing demonstrates, the public and private sector
recognition for the need for health information technology has
increased dramatically over the last several years, but nothing
could better highlight how far we still need to go than
Hurricane Katrina. As was mentioned earlier, in response to the
storm the Office of the National Coordinator, the Markle
Foundation, and 150 other public and private organizations
worked closely an intense crash effort to establish an online
service for authorized professionals to gain access to
prescription records for evacuees.
The medication history information came from a variety of
public and private sources and covered the majority of the
evacuees. This was a marvelous collaborative effort, but the
challenge of creating it had little to do with technology. In
truth, the technologies to move health information between
facilities or communities are relatively well understood and
operate today within many complex enterprises. Instead,
katrinahealth.org came into being because of good faith
commitment to overcome established business, legal, and policy
challenges to information sharing.
If there is any lesson that can be instructive going
forward, it is that a narrow focus on technical aspects of
creating an electronic health information environment will not
produce a sustainable, effective network. Longstanding policy,
legal, and business obstacles prevent our personal information
from being brought together and applied to our health needs.
To overcome these obstacles, Government leadership is
needed in three areas: policy, uniformity, and a level of
public participation that maintains focus on the needs of the
American people. The policies that govern information access,
acceptable uses, consent, privacy, and security must be crafted
in parallel with the deployment of technology if we are to have
a trusted and effective health information environment, and the
technology choices themselves must incorporate policy
objectives.
The ultimate success of efforts to promote widespread
adoption of health information technology and electronic
records will depend on the confidence and willingness of
consumers to accept and use the technology. However, several
studies note significant public concerns about the privacy of
electronic personal health data, even when most people
acknowledge the benefits.
The policies that establish who has access to health
information, what uses of information are acceptable, the
extent to which patients can give or withhold access to their
information, and the design of privacy and security safeguards
must be crafted in parallel with the deployment of technology,
and the technology choices themselves must consciously
incorporate policy objectives that protect patients.
The second area is uniformity through a common framework.
To the opening remarks on achieving goals for a broad,
nationwide health information network while making good use of
the precious, private and public sector dollars that are
invested, we must be dependent on a uniform set of standards
and policies that allow all parties who participate to adopt
and participate in information sharing.
In our work we call this a common framework, and it is
based on a network of networks in which existing healthcare
institutions agree to adhere to a small set of shared rules.
This includes technical standards and explicit policies for
information use and governance.
The key to this approach is the articulation of these
uniform policies and technical standards, and this approach
supports a complete diversity of technologies to coexist. Our
experience teaches us that the Nation will need to have an
entity to promulgate this common framework, containing both
policy and technical standards that provide structure to our
health information environment.
The AHIC recently defined by the Secretary may be the first
institutional attempt to provide these functions, and we intend
to work closely with it. The Markle Foundation is now working
with over 30 national consumer groups who are aware of the
importance of health information technology and want to help
shape this agenda. The Federal Government and Congress should
establish a meaningful process to address the issues and
priorities of the public as the AHIC and other health
information technology activities move forward.
As the AHIC and various Federal agencies begin to set
national priorities for the pace and scope of health
information adoption, they must give attention to the services
that produce high value for individual Americans, particularly
technologies that give people more access to their own
information and more control over their healthcare.
It is not enough to connect healthcare enterprises to each
other; we must also connect people to their doctors, to each
other, and to innovative resources that provide new ways to
deliver and improve health. Personal health records that can
connect doctors and other health system networks may provide
the foundation for Americans to improve the quality and safety
of the care they receive, to communicate better with their
doctors, to manage their own health, and take care of loved
ones.
Thank you again for inviting me to speak. I look forward to
responding to questions.
[The prepared statement of Dr. Diamond follows:]
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Chairman Tom Davis. Thank you very much.
Ms. Marchibroda, thank you for being here.
STATEMENT OF JANET MARCHIBRODA
Ms. Marchibroda. Thank you, Chairman Davis, distinguished
members of the committee. I am honored to be here today to
testify before you on the state of information technology, and
health information sharing, and the progress and challenges
related thereto.
My name is Janet Marchibroda. I am testifying today on
behalf of the eHealth Initiative and its foundation. I service
the CEO of both organizations which are independent, nonprofit,
national organizations whose missions are the same, to improve
the quality, safety, and efficiency of healthcare through
information and information technology. Both convene multiple
stakeholders, both within the private and public sector, to
reach agreement on and stimulate the adoption of common
principles and strategies for accelerating the use of
information to support health and healthcare.
In addition, it is important to note that through EHI, the
eHealth Initiative Foundation, we have built a coalition of
almost 1,000 stakeholders in nearly 50 States across the
country who are now mobilizing information to support
healthcare.
Despite the recent increase in interest in the use of IT to
address quality, safety, and efficiency issues, current
penetration rates continue to be low, particularly in the small
physician practices where a majority of our healthcare is
delivered. And it is also important to note while installing
electronic health records can address some of our healthcare
challenges, the real value in terms of improving quality and
safety, saving lives, reducing costs comes from the
mobilization of data across systems. You really need that
connectivity to avoid redundant tests, improve safety and
coordination, and improve consumer compliance with some of the
prevention and disease management guidelines.
Currently, the U.S. healthcare system is highly fragmented
and paper-based, and the clinicians that take care of us don't
have the information they need to deliver the best care. To
address the need for health information mobilization, a number
of collaborative organizations involving all stakeholders in
healthcare are emerging across our country to develop and
implement health information exchange capabilities, and the
policies and processes that will support their ongoing
operations.
The eHealth Initiative Foundation recently conducted its
second annual survey of State, regional and community-based
health information exchange efforts, and we released our
results in late August. What the survey results indicated was a
dramatic increase in the level of interest in and activity
related to mobilizing information. It showed that there are a
lot more of them this year, and those that are out there are
much more mature in terms of organization and governance,
getting all the stakeholders to the table, and the range of
functionality provided. Among the 109 health information
exchange efforts identified by the survey, there is clear
evidence of rapid maturation and movement with 40 respondents
in the implementation phase and 25 fully operational, up from 9
last year.
In terms of the barriers to getting to an interoperable
healthcare system, we see two: the first being the misalignment
of incentives and lack of a sustainable business model for IT;
and two, the need for standards adoption and interoperability.
Physicians have a real tough time. They face a significant
financial hurdle when exploring the purchase of an EHR system.
What we found in our 2005 survey was, while these health
information exchange initiatives are growing and maturing, the
No. 1 key challenge, 84 percent of them actually cited
developing a sustainable business model as either being a very
difficult or moderately difficult challenge.
Achieving sustainability for health information exchange
efforts stems in part from fundamental problems with our
Nation's prevailing reimbursement methods which reward the
volume of services delivered instead of outcomes or processes
that would result in higher quality care. A lot of progress is
being made with the value-based purchasing legislation that is
coming out and the leadership of the Centers for Medicaid and
Medicare Services, as well as groups such as Bridges to
Excellence in the private sector. We have developed a set of
principles and policies bringing together employers, health
plans, and practicing clinicians, and these community-based
efforts that will begin to align incentives that we provide in
healthcare, not only with quality and efficiency goals but also
with HIT capabilities within the community.
Great progress is being made around standards and
operability, interoperability, which we have heard from the
other parts of our panel, and a number of efforts are underway
with a number of bills in Congress. Finally, in closing, the
Office of Personnel Management through its Federal Employees
Health Benefits Program has an enormous opportunity to affect
change in our healthcare system given that 8 million Federal
employees, retirees, and their dependents are reliant on the
program. By building into those incentive programs, policies
related to health information exchange, we can make real
progress.
So in conclusion, we offer a very brief summary of key
points. Without the alignment of financial and other
incentives, not just with quality and efficiency but also
health information exchange, efforts to accelerate the
mobilization of information will continue to move at a slow
pace, and the combined purchasing power of both CMS and OPM can
make great progress in this area.
Two, innovative programs designed to facilitate both public
and private sector seed funding of these emerging community
health information exchange efforts must be developed and
implemented, if our goals around widespread interoperability
are to be achieved. And three, national efforts designed to
achieve consensus on standards and promote their adoption could
not be more timely, particularly for our communities across
America that are on the ground making this happen.
We are at a unique point in time where we have a lot of
momentum moving around these issues. If we focus on moving our
quality and efficiency goals, and at the same time those
related to health information technology, we will make great
progress.
Chairman Davis, distinguished members of the committee,
thank you again for inviting me to discuss our perspectives. I
hereby request that the Parallel Pathways Framework for
Incentives and our survey of State, regional, and community-
based initiatives that are referenced in my testimony be made
part of the record.
Chairman Tom Davis. Without objection.
Ms. Marchibroda. We commend you for your leadership. And,
again, thank you for the opportunity to join you.
[The prepared statement of Ms. Marchibroda follows:]
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Chairman Tom Davis. Well, thank you very much.
Ms. Carr.
STATEMENT OF DIANE CARR
Ms. Carr. Good morning, Mr. Chairman and members of the
committee. I would like to thank you for this opportunity to
share the experience of a public hospital in New York City in
transforming healthcare with technology.
Queens Health Network is the largest healthcare provider in
the borough of Queens, New York City. We serve a population of
about 2 million people. We include two major teaching
hospitals, Elmhurst Hospital Center and Queens Hospital Center,
and have a combined total of 771 inpatient beds and see 43,000
annual admissions. We are affiliated with the Mount Sinai
School of Medicine and a member of the New York City Health and
Hospitals Corp. which is the largest municipal healthcare
organization in the United States.
Our service model is unique. I just want to mention that
for a moment because, in addition to providing acute hospital
care including tertiary care, we also provide a full range of
services of primary care and specialty care services. We serve
as many of our patients family doctors. We do that, in addition
to our on campus locations in 14 freestanding medical clinics
and 6 school-based health programs where we provide care to
children at their school, similar to what many of us
experienced with school nurses. We have a partnership with
community-based physician practice groups, and we see over 1
million ambulatory visits a year. So we are a pretty high
volume healthcare provider.
I just want to mention about the community we serve because
there is some uniqueness to that as well. It is probably the
most ethnically diverse region in the world. We have immigrants
from over 100 different countries speaking 167 different
languages and 87 percent of our patient population is people of
color and ethnic minorities.
Our residents are also some of New York City's poorest.
Sixty-five percent of the households in our service area have
annual incomes under $15,000. Because of this, our patient
population is also medically under-served. They are denied care
in other venues due to inability to pay, and they are generally
unaware of preventive practices that promote good health. They
present sicker than the general population.
In the mid 1990's, Queens Health Network faced a dilemma,
how to maintain and expand services for an ever increasing
number of uninsured patients in an ever more demanding
marketplace. As part of our business and strategic plan, senior
administration proposed implementation of an electronic health
record to our medical staff.
In January 1997, we began with computerized physician order
entry. Our doctors started ordering all of their lab and
radiology results and looking them up online. We had no idea at
the time how early we were undertaking this. Today we have a
fully integrated, interdisciplinary health record that is used
by over 4,300 people every day. This is all of our doctors, our
nurses, our pharmacists, social workers, dieticians, lab and
radiology techs use the system all day, every day, to enter
orders, review results, do assessments and plans, histories and
physical examinations, and medical orders.
We provide a full range of electronic decision support to
improve safety and effectiveness of care. So what we have
discovered in the experience of installing our electronic
health record is that it is essential to improving patient
safety, effectiveness of care and also in reducing costs.
Chronic disease is the leading cause of illness,
disability, and death in the United States today. Nearly half
of the population, 100 million Americans, have one or more
chronic medical conditions. The costs of the treatment is
enormous in accounting for nearly 70 percent of all personal
healthcare expenditures in the country. The electronic health
record can provide a structure for applying evidence to patient
care to improve care of patients with chronic diseases.
So we have targeted heart failure, diabetes, and depression
right now as populations of patients who can benefit from
analysis and aggregation of data, which helps us to evaluate
therapies and treatments on patient outcomes. For example, if
we have cardiologists working in adjoining rooms with patients
with the same disease, we may not know what is going on with
them individually, but when we start to aggregate their data we
can look at patterns and see rooms for improvements.
The final point that I want to make is that, with all the
discussion of interoperability, I think you also have to start
somewhere and that the electronic health record is the place
that will provide a starting point. If you don't have
electronic health record that you can share your patient
information from, interoperability means nothing, that is it.
Chairman Tom Davis. OK. You have concluded?
Ms. Carr. Yes.
[The prepared statement of Ms. Carr follows:]
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Chairman Tom Davis. Mr. Blue, go ahead. We have a vote, but
if we can hurry this up, we can get some questions in.
Mr. Blue. I will try and speak as quickly as I can, Mr.
Chairman.
Chairman Tom Davis. Then we can go. Otherwise, we have to
come back.
STATEMENT OF LARRY BLUE
Mr. Blue. Mr. Chairman Davis and distinguished members of
the committee, thank you very much for the opportunity to
testify today and for holding this very important hearing on
how we can use information technology to improve the quality of
healthcare in this country. I would like to focus my remarks
today on two specific areas, reducing medical areas and using
RFID to fight the rising tide of counterfeit drugs.
First, let me tell you a little bit about Symbol
Technologies. Symbol manufactures handheld computers that scan
bar codes and read RFID tags. We also manufacture wireless
networks that tie together large scale asset management
systems, so information is available where it is needed in real
time. We help our clients capture, move, and manage
information. Today these tools are being used to dramatically
improve the delivery of healthcare by making medical
information where and when it is needed, at a patient's
bedside, in an operating room, or on a battlefield.
Medical errors are a serious problem facing the healthcare
industry today. The Institute of Medicine estimates that
preventable deaths due to medical errors are between 44,000 and
98,000 annually, and adverse drug events cause more than
770,000 injuries per year.
With aging parents and as a father of three great kids, I
was pleased to see that reducing medical errors is one of the
central goals of the national healthcare strategy. In our view,
the keys to reducing medical errors are: first, converting
patient records from paper to electronic records as presented
in Dr. Brailer's earlier testimony and by other testimony
today; and second, delivering accurate information to the
patient's bedside in right time.
Once a medical center adopts electronic patient records,
the next step is to adopt mobility technology so that
information is available at a doctor's or nurse's fingertips
anywhere in the complex. Patients move from hospital rooms to
radiology centers to operating rooms in the normal course of
their treatment, and their information has to follow them.
Some hospitals now assign a barcode to a patient when he or
she checks in. It is put right on their wristband. When a nurse
is making rounds and stops in a patient's room, he or she can
scan the barcode on the patient's wrist with a handheld
computer similar to the PDA many of you carry today. The
handheld then wirelessly retrieves the patient's medical
records and displays the last times medicines were delivered,
when the next dose is due, and exactly how much of which
medicines to administer. The nurse can deliver the right
medicines in the right doses at the right time, and immediately
update the patient's record electronically.
One real life example of this system in action can be seen
at the VA. The Veterans Administration deserves an enormous
amount of credit for implementing this type of patient
identification and health information mobility system and
improving patient care as a result. A hundred percent of VA
medical centers are currently using barcode technology to
identify patients and medication, and medication errors have
been reduced significantly. Unfortunately, the adoption of
these important solutions in commercial hospitals is estimated
at less than 20 percent.
One of the most significant barriers to hospitals
implementing this type of system has been the lack of a uniform
barcode on medications. Up until now, healthcare providers have
had to develop their own barcodes and apply them to drug
packages which is costly, can be error prone, and is time
consuming.
We applaud the FDA's new regulations requiring barcodes on
all medications by April 2006. This should make these systems
much easier to implement and will enable more effective
information exchange within and between facilities during
patient transport, treatment, and transfer.
The second topic of my remarks relates to the serious
problem of counterfeit prescription drugs. This affects not
only patients here in the United States but around the world.
The World Health Organization estimates that prescription drug
counterfeiting is a $32 billion global business.
New technologies are being employed to combat counterfeit
drugs, and one of them is RFID. RFID stands for Radio Frequency
Identification. It is the next generation of barcode. A tiny
computer chip attached to an antenna is placed on a product.
When it is activated by a reader, it transmits a serial number
or unique identifier to an authorized device. That number is
then used to retrieve information such as an EHR from a secured
data base.
The FDA and private industry are aggressively developing
electronic track and trace systems using RFID to stop
counterfeiting. The goal of these systems is to create an
electronic pedigree for legitimate drugs. Symbol is actively
working with Perdue Pharmaceuticals to develop such a system
for Oxycontin which is one of the top counterfeited and stolen
medications in the United States. Early results of our trials
are encouraging, and we are optimistic that this RFID-based
system is going to create a real barrier to thieves and black
marketeers.
For health IT systems and technologies to be effective,
they have to be interoperable; and to be interoperable, we need
industry-wide standards. Without standards, data from one
company or medical center won't be understood at another, and
one company's RFID readers won't read another company's tags,
and so on.
In my industry, I have personally worked to develop
standards for RFID and electronic product codes. A group called
EPC Global has done a great job getting industry together to
create a common RFID data standard. I believe standardization
is critical to widespread implementation and unlocking the
value of a new technology. In this case standards can mean the
difference between only one hospital having an electronic
patient record and the ability of that hospital to freely share
that record with any other healthcare provider needed by that
patient.
As the economy has become global, it is now more important
than ever for these data exchange standards to be global.
Health care products consumed in the United States are
manufactured globally, and global standards is one area where
Congress and the administration can help us. If the Federal
Government can reinforce the message to industry in foreign
countries that cooperation on common barcodes, EHRs, and other
data exchange standards like RFID is a high priority, that
would be very helpful.
Thank you again for the opportunity to testify today, and I
would be happy to answer any questions you have.
[The prepared statement of Mr. Blue follows:]
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Chairman Tom Davis. Thank you very much. Let me start. Mr.
Powner, as you know from our FISMA score card, you know this
committee likes grades. Can you try to give the administration
a grade in its efforts to develop a national strategy for
health IT including its efforts to define and implement
standards?
Mr. Powner. From a leadership and vision perspective,
clearly, Dr. Brailer and the efforts at HHS and the
administration deserve an A. If you look beyond that in terms
of putting in place plans and getting down to the
implementation, we are incomplete. We are far from having plans
and marching orders in place and a complete game plan to tackle
this enormous challenge.
Chairman Tom Davis. Thank you very much.
Ms. Carr, how long did it take to fully implement
electronic health records in the Queens Health Network?
Ms. Carr. Mr. Chairman, in 6 months we went from a twinkle
in our eye to having our physicians doing order entry online.
Chairman Tom Davis. How did you get the buy-in from
physicians?
Ms. Carr. I guess what we did is we had a really serious
challenge in terms of the volume of activity that we needed to
support. And we demonstrated that with this technology, we
could increase our capacity and take better care of our
patients.
Chairman Tom Davis. Thank you.
Mr. Blue, do you think that health IT systems are more
vulnerable and more attractive to hackers and cyber attack
because of the quantity of personal information they hold?
Mr. Blue. My own personal opinion, Mr. Chairman, is no, I
do not believe so. I believe that they are vulnerable to attack
like all data bases, but there is a lot of work that has been
done both in industry and in Government to assure through
opportunities like HIPAA, and I believe one of the prior
testimonies discussed the advantage of information technology
in protecting that data and also making it more readily
available to the people that need it. So I don't believe so.
Chairman Tom Davis. Dr. Diamond, your testimony mentions
the problem of patients being concerned that a system of
electronic health records could result in the exposure of
private health information, which I just asked Mr. Blue a
question about. How are you working to manage public perception
that privacy could be compromised?
Dr. Diamond. Yes. Yes, I think----
Chairman Tom Davis. Because we see the credit card
companies and everything else on these things.
Dr. Diamond. You took the words out of my mouth. I was just
going to say, Mr. Chairman, that I think we have all seen the
newspaper stories about credit card data being stolen, and
other third party data bases being hacked, and consumers'
identity being stolen. I am of the belief that this is a broad
IT sector issue that needs to be solved.
But I think for healthcare, in particular, our approach is
to build the need to protect privacy and security in on the
front end of this technology and architecture. And one of the
models we propose, the model we propose to do that is to
separate the medical data, the location of the medical data
from the actual data itself, so that we are not proposing
putting everyone's information in one large central data base,
but just having the network and the infrastructure available to
know where it is when it is needed, and not have to put it in
one place which is a single point of attack or a hacker's dream
potentially.
Chairman Tom Davis. Thank you.
Ms. Marchibroda, are State and local health IT initiatives
coordinated with Federal strategy?
Ms. Marchibroda. Thank you, Chairman. They would like to
be. I think something that EHI is doing right now is taking the
national standards and policies that are merging from the
Federal Government as well as initiatives like Connecting for
Health, and creating tool kits and guides to help these States
and regions who very much want to be in sync with national
principles and standards, provide them with guides to help them
get there.
Chairman Tom Davis. OK.
Ms. Marchibroda. There is still more work to do.
Chairman Tom Davis. I will ask anybody: What metrics would
you use to gauge the success of the National Coordinator's
Office? Anybody want to take a shot at that? Any volunteers? Go
ahead, Mr. Powner.
Mr. Powner. Ultimately, I think--Mr. Blue mentioned this--I
think one of the key metrics we really need to focus on long
term here is the reduction of medical errors. When you look at
the staggering figures that come out associated with medical
errors, the number of people who actually die in a given year,
that is clearly a metric where the incorporation of health IT
can clearly move us in the right direction.
Chairman Tom Davis. Thank you. We have about 3 minutes left
in our vote. I could hold you over for a couple votes, but I
think what I will do is just adjourn the hearing at this point.
We may have some questions for the record from each of you,
but we appreciate your statements. It is all in the record and
will all be used as we move ahead. I thank you for your time.
The meeting is adjourned.
[Whereupon, at 12:03 p.m., the committee was adjourned.]
[The prepared statements of Hon. Dennis J. Kucinich and
Hon. John M. McHugh, and additional information submitted for
the hearing record follow:]
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